HEENT Assessment

Obtaining History

If head or neck trauma, gather CC and current status info. Postpone rest of history until x-rays obtained.

History: Head and Neck

• Head trauma, skull surgery, jaw/facial fractures?

• Headaches?• Swelling of face, jaws, mastoid

process?• Sinus infections/tenderness?• Nasal discharge or post-nasal drip?• Nosebleeds?

History: Head and Neck

• Mouth lesions, ulcers, or cold sores?• Any difficulty swallowing or

chewing?• Any changes in sound of voice?• Any allergies causing breathing

difficulty?• Any neck injury or surgery?

Additional Questions: Peds• Drinking water treated with

fluoride?• Use pacifier or thumb?• When did teething begin?• Tonsils present? If not, when

removed?

Additional Questions: Elderly• Do you wear dentures?• If so, how well do they fit?

Health Promotion Questions• Smoke a pipe? Chew tobacco or use snuff?• Does relaxation, exercise, or massage help

relieve headaches?• Is H/A associated with lack of sleep, missed

meals, or stress?• Job: sitting at computer terminal?, risk of

head injury? (hard hat?)• Do you grind your teeth? Last exam? Floss?• Use seat belts?

Examination of Head, Neck, and Lymph

Hair and Scalp: Inspection

• Quality and thickness• Distribution, pattern of loss (if any)• Texture• Lesions• Presence of nits

Skull: Inspection/Palpation

• General size and contour• Deformities, lumps and tenderness• Palpate sinus areas and mastoid

areas for tenderness• Palpate temporal artery• Check TMJ

Face: Inspection

• Facial expression• Symmetry• Involuntary movements• Edema• Masses or lesions• Color and texture of skin• Exopthalmos• Rash

Neck: Inspection

• Asymmetry• Range of motion• Abnormal pulsations, vein distension• Enlargement of thyroid, lymph, salivary

glands• Deviation of trachea• Skin lesions• Neck muscles

Neck: Palpation

• Assess lymph nodes, noting:– exact location– size and shape– tender?– freely movable, adherent or matted

together?– texture: hard, soft, firm

• Thyroid gland• Trachea

Neck: Auscultation

• Check for bruits:– carotid arteries– temporal arteries– thyroid, if enlarged

Lymph Nodes: When to Biopsy?• Immediate biopsy is indicated for:

– painless– rubbery node of recent onset– especially if > 1-2 cm in diameter

• A smaller, rapidly enlarging node is also a biopsy candidate.

• Unilateral nodes should have a biopsy sooner than bilateral ones.

• More conservative with stable node.

Eyes

History: Eyes

• Corrective lenses? Glasses/contacts?• When lenses last changed?• Blurred vision?• Spots, floaters, halos around lights?• Frequent eye

infections/inflammation?• Eye surgery or injury?• Styes?

History: Eyes

• History of high blood pressure or diabetes?

• Any prescription medications for your eyes?

• Family history: cataracts, glaucoma, blindness?

Eye History: Peds

• Infant: gaze at you or other objects; blink at bright lights or quick movements?

• Eyes ever crossed? Ever move in different directions?

• Does child bump into things?• Does child sit near television at home?• How is child’s progress in school?

Eye History: Elderly

• Do eyes feel dry?• Difficulty seeing in front of you but

not to the sides?• Problems with glare?• Problems discerning colors?• Difficulty seeing at night?

Health Promotion Questions• Last eye examination?• Eye care insurance?• Occupation: prolonged reading or

use of video display terminal?• Any eye problems from air at

work/home?• Use goggles when appropriate?

(when using tools, sports, swimming?)

Examination of the Eye

• Visual acuity• External Eye Exam (SIMPLE):

– Symmetry– Inflammation– Masses– Puncta– Lacrimal duct– Eyelinds

Abnormalities: External Eye Exam• Lid lag• Lid ophthalmus

(incomplete closure)• Ptosis (drooping)• Blepharospasm• Xanthelasma• Ectropion (rolling

out)• Entropion (rolling in)

• Infections:– hordeolum (sty)– chalazion– blepharitis

Conjunctiva

• Palpebral conjunctiva: lines lid• Bulbar conjunctiva: over sclera• Conjunctivitis: viral, bacterial,

allergic

• Pterygium: thickening of bulbar conjunctiva

Ocular Muscles

CN III Upper Outer Superior Rectus

CN III Upper Inner Inferior Oblique

CN III Lower Outer Inferior Rectus

CN III Lateral Inner Medial Rectus

CN IV Lower Inner Superior Oblique

CN VI Lateral Outer Lateral Rectus

Strabismus: Deviation of Eye• Tropia:

Malalignment or deviation of eye

• Exotropia: outward turning

• Esotropia: inward turning

• Phoria: Mild weakness apparent only with cover test

• Exophoria: outward drift

• Esophoria: inward drift

Globe

• Cornea– Clear, smooth– Arcus senilis– Corneal reflex

• CN V Trigeminal• CN VII Facial

• Sclera

Globe

• Pupil– Size (3-5 mm)

• Anisocoria: unequal pupils

– Light reflex– Convergence– Accommodation

• Iris• Lens

Testing Peripheral Vision

• 60o Nasal

• 90o Temporal

• 60o Superior

• 70o Inferior

With Any Eye Pain:

• Numb eye with Tetracaine

• Use fluorescein paper (wet with sterile saline or water)

• Use Wood’s light to check for abrasions, foreign body

The “Red Eye”

Differential Diagnosis

Conjunctivitis

• If blurring: intermittent, clears on blinking

• Discharge: usually, crusting of lashes• Pain: none or minor and superficial• Pupils: Normal size and response• Conjunctival Injection: Diffuse• IOP: Normal (don’t measure if discharge)• Cornea: Clear

Iritis

• Vision: slightly blurred• No discharge• Pain: Moderately severe, aching,

photophobia• Pupil: constricted, minimal response• Conjunctival injection: Circumcorneal• IOP: Normal to low• Cornea: clear or slightly hazy

Keratitis (Corneal inflammation or foreign body)• Vision: slightly blurred• Discharge: none to mild• Pain: sharp, severe foreign body sensation• Pupil: normal or constricted, normal

response• Conjunctival injection: circumcorneal• IOP: Normal (Caution: do not measure)• Cornea: Opacification present; altered light reflex; (+)

fluorescein staining

Acute Glaucoma (REFER)

• Vision: marked blurring• Discharge: none• Pain: very severe, frequently N & V• Pupil: dilated, minimal or no reaction• Conjunctival injection: diffuse with

prominent circumcorneal injection• IOP: elevated• Cornea: hazy; altered light reflex• Anterior chamber depth: shallow

Fundoscopic Exam

When to do Fundoscopic Exam• Suspected neuro problems

– headache– dizziness

• Diabetes• Hypertension• Toxoplasmosis

Optic Disk

• Size: 1.5 mm• Shape: round--> slightly oval• Color: salmon pink, yellowish-white• Margins: distinct, fuzzy nasally• Disc-cup ratio: Physiologic

cup/Optic disk should be < .5• Normal variations

Retinal Vessels

• Number: Branches to all four quadrants• Color: arteries brighter than veins

(veins slightly darker and larger than arteries)

• A-V ratio (diameters): A/V > 1/2 (1/2 or less may mean diabetes)

• A-V Crossing: should cross with no disruption of blood flow (if flow impaired = A-V nicking)

Macula (central vision)

• Location: 2 disc diameters temporally from disc

• Fovea = center of macula• NOTE: Uncomfortable for patients

to have light shined on macula; aim for disc instead

• Abnormalities

General Background of Fundus• Color: bright orange/red; consistent OU• Abnormalities:

– microaneurysms– hemorrhage– hard exudate: creamy or yellowish, well-

defined borders– cotton wood spots (soft exudate):

white/gray ovoid lesions with irregular borders

Ears

History: Ears

• Any hearing differences in one/both ears?• Ear pain?• Trouble with earwax? What is done?• Ear injury? Ear surgery?• Ringing or cracking in your ears?• Foreign body in ear?• Frequent ear infections? Drainage?• Problems with balance, dizziness, vertigo?

History: Ears

• Rx or OTC meds or home remedies for the ears or any other conditions?

• Family: anyone with hearing problems?

• Occupational history

Ear History: Peds

• Infant: respond to loud or unusual noises?• If > 6 months, does infant babble?• If > 15 months, does toddle rely on

gestures and make no attempt at sound?• Child tugging at either ear?• Any coordination problems?• Hx: meningitis, recurrent OM, mumps,

encephalitis?

Ear History: Elderly

• Any recent change in hearing?• Wear a hearing aid?• If so, for how long?• How do you care for it?

Health Promotion Questions• Last ear exam/hearing test?• Results of test?• Any meds for ears?• Any concerns about ears/hearing?• Do you work around loud

equipment or machinery? (or LOUD MUSIC!)

Ear Assessment: Concepts• Lightheadedness: detachment

• Vertigo: surroundings swirling around

• Dizziness: disturbance in relationship to space

Hearing Loss

• Otosclerosis: Bones fuse; ages 40-50 have some degree of hearing loss

• Conductive hearing loss: sound not getting to hearing apparatus

• Sensory hearing loss: High pitched sounds are the first to NOT be heard.

• Mixed hearing loss

External Ear: Inspection

• Pinna (auricle)– Size and shape– Level on head– Flat or protruding– Tophi or nodules

• External Auditory Canal– Cerumen, discharge, foreign bodies– Signs of infection

External Ear: Palpation

• Tophi and nodules• Assess for tenderness (with ear

pain, discharge or inflammation)– move auricle– press on tragus– press on mastoid

Otoscopic Exam

• Technique– Pinna up, back and out in adults– Pinna down and out in children– Advance slowly; ANCHOR the

otoscope

• Observe canal: blood, tumors, wax, foreign bodies

Otoscopic Exam: Tympanic membrane (drum)• Note color and luster• Oval thin, partially transparent grey• Gently move speculum to inspect

entire ear drum• Landmarks• NOTE: The more scarring on the TM

from healed ruptures, the less mobile it becomes ---> conductive hearing loss.

Testing Hearing

• Crude Tests– Watch test– Whisper test

• Tuning Fork• Weber test• Rinne’s test

Types of Hearing Loss

Hearing Loss Weber Test Rinne Test

Sensorineural Hear in goodear

AC>BC(normal)

Conductive Hear inimpaired ear

BC> or = AC(abnormal)

Vestibular Testing

• Romberg’s sign

• Post pointing

• Nystagmus

Nose, Throat, Mouth and Sinus

Nose

• Inspect for deformity, asymmetry, and inflammation

• Test for patency of each nostril• Using speculum, note:

– color of nasal mucosa– spectum, bleeding, perforation, deviation– turbinates: visible, color, swelling,

exudate, polyps

Mouth and Throat• Lips, Tongue, Gums and teeth• Buccal mucosa• Palata and uvula• Tonsils and pharyngeal wall• Ducts• Frenulum• Note: sore throat may be due to PND

Sinuses

• Able to assess:– frontal sinus– maxillary sinuses

• Others– ethmoid sinus– sphenoid sinus

• Palpate for sinus tenderness in adult• Transillumination