The Head and NeckLecture 1

Dr. Maysa AlmomaniNur 206, Fall 2015

Chapter 7

Head, Eyes, Ears, Nose, Throat, (HEENT),& Neck

• Identify key anatomic structures important in examining H & N– Regions of the skull– Anatomic detail of the eye– Three bones of middle ear, auricle, & pinna– Nasal turbinates– Sinuses– Nine groups of cervical lymph nodes

Assessment Techniques for HEENT & Neck• Visual acuity• Extraocular movements• Pupillary reaction• Fundoscopic exam

• Auditory acuity

• Oral and pharyngeal mucosa• Gums, • Cervical lymph nodes, • Cricoid cartilage, • Thyroid isthmus and lobes

HEENT History• Descriptors1. Mode of onset

a. describe events coincident with onsetb. onset gradual or sudden?c. total duration of the symptom

2. Location of the symptom3. Character of the symptom4. Radiation of the symptom5. Frequency of the symptom6. Precipitating factors7. Aggravating factors

HEENT History8. Relieving factors9. Associated symptoms10. Course of symptoms (getting worse, better, etc)11. Effect of symptoms on daily life12. Past treatment or evaluation of the symptom

a. when, where, by whom?b. what studies were done and what were the results?c. results of past treatmentd. past diagnosis

13. Patients concerns

The Head

Health History (Head)Headaches

• Full description and 7 attributes of pain:

1. Location (One-sided, bilateral, radiates? )

2. Quality (what is it like?) Steady or throbbing?

3. Quantity or severity (how bad? Pain Rating scale)

4. Timing (when does/did it occur? For how long? How often?) Continuous or comes and goes?

Headaches5. Setting in which it occurs (environmental,

activities, emotional reaction, circumstances)6. Remitting or exacerbating (anything makes it

better or worse?) e.g. coughing, sneezing, changing positions

7. Associated manifestations (anything else that accompanies pain?) e.g. nausea, vomiting, neurological, such as change in vision or motor sensory deficits

• Point to area of pain and discomfort• Family History (migraine)

Types of Headache• Tension headache (bilateral, generalized or localized to

back of head: muscle tension, emotional)• Migraine (dilatation of arteries outside or inside the skull,

or generalized: tension, foods, PMS, noise, bright light)• Cluster headache (face pain, unilateral stuffy, runny nose,

reddening and tearing of the eye)• Vascular headache (dilatation of arteries inside skull,

generalized: due to caffeine withdrawal, fever)• Headaches with eye disorders (face pain: due to

farsightedness, astigmatism, acute glaucoma, increased IOP)

SEE Table 7-1(p. 249)

Head – Inspection and Palpation

• Inspect

– Hair distribution, quantity

– Scalp – scaling, nevi

– Skull – size, contour

– Face – expression, contours

– Skin – color, pigmentation, hair distribution, lesions

• Palpate– Hair texture

– Skull – lumps– Face – sinuses– Skin – texture,

temperature

Examining the Head• The hair

– I: Quantity, distribution, pattern of loss, – P: texture,

• The scalp– Scaling, nevi, lesion

• The skull– General size and contour, deformities, – depressions, lumps, tenderness

Examining the Head• The face

– Facial expression, contour, symmetry, features, movement, edema, masses

– sinuses

• The skin– Color, pigmentation, thickness, hair

distribution, lesions– texture, temperature

Anatomy of the Eye

Puncta

Pupil

Limbus

Iris

Anatomy of the Eye• Tear fluid protects the conjunctiva & cornea from :

drying & inhibits microbial growthgives a smooth optical surface to the cornea

The fluid comes from:-meibomian glands within the eyelids-conjunctival glands-lacrimal glands lies mostly within the bony orbit-

The Eye

The Eye

• Aqueous humor is a clear liquid fills the anterior and posterior champers of the eye.

• It is produced by the ciliary body, circulates from the posterior chamber the pupil anterior chamber drains out through the canal of Schlemm

• This circulation control the pressure inside the eye

Circulation of Aqueous Humor

Optic chiasm, at the base of the frontal lobe of the brain

The Eye

• Eye and vision problems

• Change in vision?

• Is the onset sudden or gradual sudden visual loss suggests: retinal

detachment and occlusion of the central retinal artery.

The Health History (Eye)• Common or concerning symptoms

– Worse during close work or at distances?• Hyperopia (farsightedness)

• Presbyopia ((aging vision) inability to focus on near objects that often occurs in middle-aged persons)

• Myopia (nearsightedness)

– Blurring? Macular degeneration, peripheral loss in advanced glaucoma, one-sided loss in hemianopsia

The Eye

• Scotomas (spots or specks in the vision / areas where the patient cannot see & suggesting

– move around with eye movement (vitreous floaters)

– fixed (lesions in the retinas or visual pathway)

• Flashing lights (detachment of vitreous from retina)

• Pain in or around the eyes, redness, excessive tearing or watering

The Eye

• Double vision (diplopia): due to lesion in brain stem or cerebellum, Extra ocular muscle weakness or paralysis– Horizontal (cranial nerve III, VI)– Vertical– Which eye? One eye cornea or lens

Examining the Eye• Visual acuity• Visual fields• Conjunctiva & Sclera• Cornea, lens, pupils• Extraocular movements• Fundi, including

– Optic disk and cup– Retina– Retinal vessels

Visual Acuity• Snellen Eye Chart (to test the acuity of central

vision)– Position 20 feet from the chart– Put your glasses if you use them– Cover one eye with the card– Read smallest line possible– Position patient closer to chart, if can’t read

largest letter– Note the distance

Snellen Eye Chart–The smallest row that can be read

accurately indicates the patient's visual acuity in that eye

–e.g. 20/30*20 indicates the distance of the pt.

*30 indicates the distance at which a normal person can read the line

Snellen Eye Chart• “20/40 corrected”Patient could read the 40 line with glasses (a

correction)

• In US, a person considered legally blind when the vision in the better eye, corrected by glasses, is 20/200 or less.

Snellen Eye ChartEstimates visual acuityIn each eye separately

Visual Fields by Confrontation

• Normal:- Assuming the examiner has normal field of vision, patient should have the same extent of field of vision.- If you find a defect, test one eye at time- Use a small red object

Visual Fields by Confrontation• Screening: temporal quadrants of each eye by confrontation• Technique

– Position self in front of patient. – nose is medial field of vision. – Patient's right eye to your left eye and vice versa. – Patient to look straight not move eyes. – Place your hands about 2 feet apart– Compare your field of vision with the patient. – Bring your finger from the right field of vision until it is

recognized– Test all four quadrants. Both eyes at same time Abn.: one eye at a time

http://www.youtube.com/watch?nomobile=1&edufilter=_RCxmPbsbl2nprwt8_MfhA&v=jdaq-Ecz7Co

• Normal: Assuming the examiner has normal field of vision, patient should have the same extent of field of vision.

Visual Fields• Abnormality reflects lesion in visual pathways• Localizing a lesion

– Neurologic lesions– Optic nerve lesion

• Blind spots• Scotomas • Homonymous hemianopsia (optic tract). A loss of

vision in the nasal half of the visual field of one eye and the temporal half of the visual field of the other eye.

• Bitemporal hemianopsia (optic chiasm). Hemianopia in the temporal halves of the visual fields of both eyes.

• Quadrantic defects (optic radiation partial )

See book page 254 Table 7-5

External Examination of the Eyes - Inspection

• Position and alignment of the eye– Assess inward or outward deviation, abnormal

protrusion, such as ocular tumors

• Eyebrows - quantity and distribution– Scaliness/ scaling (seborrheic dermatitis)– lateral thinning in hypothyroidism

External Examination of the Eyes - Inspection

• Eyelids – Surrounding tissues – Width palpebral fissure– Edema of lids– Color of lids– Lesions– Condition & direction of eyelashes (ectropian: lower

lid outward, entropian: inward)

– Adequacy of eyelid closure (prominent eyes, facial paralysis)

External Examination of the Eyes - Inspection

• Lacrimal apparatus– Excess tearing or dryness– Lacrimal gland and lacrimal sac for swelling– Tear drainage from nasolacrimal duct (characteristics)

• Conjunctiva and sclera– Color (&translucency), vascular pattern, nodules,

swelling ( yellow sclera indicates jaundice)

* ask patients to look up as you depress both lower lids with your thumbs inspect for color and vascular patterns.

External Examination of the Eyes - Inspection

• Cornea and lens– Oblique lighting (from 2 feets)– Check for opacities,

• Iris: markings clearly defined– Anterior chamber: Apply tangential light to cornea

and assess whether you are able to see the entire Iris without a shadow

– Normally flat, crescentic shadow indicates “narrow angle glaucoma blocked drainage of aqueous humor and increase IOP"

External Examination of the Eyes - Inspection

• Pupils (pt look at a distant object & Flash a light) – Assess pupillary size, shape, symmetry, reactions (cranial

nerves II and III )– Large> 5mm (mydriasis: dilation), small <3mm (miosis:

constriction)– Direct reaction (pupillary constriction in same eye)– Consensual reaction (pupillary constriction in the

opposite eye)– If the light reaction is absent , test the near reaction

– Prevent near reaction by using both the distance and the oblique lighting.

– Darken the room and use bright light.

External Examination of the EyeThe Near Reaction

• Technique: – Patient head still– Watch examiner’s finger– Move slowly

• Accommodation and convergence– Ask the patient to follow your finger as you bring it toward

the bridge of his nose. – Note the convergence of the eyes and pupillary

constriction.• Normal: Convergence should be sustainable to

within 5-8 cm & both pupils constrict• poor ……in hyperthyroidism

Normal Findings • 20/20 vision • Eye balls are symmetrical in size and position.

• The upper lid covers upper portion of cornea , when the patient is looking straight.

• Eye lashes span outwards

• Lacrimal apparatus: Small lacrimal gland is recognizable.

• Hair distribution in eyebrows is in its entire length • The sclera is white in color

• The palpebral conjunctiva appears pink.

Normal Findings• Cornea is translucent, smooth and a vascular.

• Anterior chamber is clear with aqueous humor

• Iris is flat and color varies • No shadow is cast when Iris is visualized with a

tangential light • no evidence of glaucoma

• Pupil is centrally located in the Iris

• Lens is transparent and uniform in density

Normal Findings

• Pupils are subtle, mild 0.05mm anisocoria (unequal in size) by itself and not necessarily an abnormal findings.

• Pupil size is 3-5 mm in diameter. • They react briskly to light. • Both pupils constrict consensually.

View of the eye muscles EOM

View of the eye muscles

Extraocular muscles (EOMs) (movement of the eye)

• Extraocular muscles (movement of eyes, cranial nerves III, IV, VI, & the six Extraocular muscles they innervate)

– Oculomotor nerve (III)- right inferior rectus (responsible for moving the eye: most muscles of the orbit)

– Trochlear nerve (IV)- superior oblique muscle (moves eye downward)

– Abducens nerve (VI): lateral rectus muscle (moves eye laterally)

Extraocular muscles (EOMs) (movement of the eye)

• Ask pt to follow your finger or pencil through the six directions of gaze-to the pt extreme right-to the right and upward-down on the right-to the extreme left-to the left and upward-down on the left

Extraocular Movement

Trace “H”

Left EyeMovement,

Cranial Nerves, & Muscles involved

• The superior rectus muscle is a muscle in the orbit that elevates, adducts, and rotates the eye medially.

• As with most of the muscles of the orbit, it is innervated by the oculomotor nerve (Cranial Nerve III).

• The inferior rectus muscle is a muscle in the orbit that depresses, adducts, and rotates the eye laterally.

• As with most of the muscles of the orbit, it is innervated by the oculomotor nerve (Cranial Nerve III).

• The lateral rectus muscle is a muscle in the orbit that abducts the eyeball (makes it move outwards).

• It is the only muscle of the orbit innervated by the abducent nerve (Cranial Nerve VI).

.

• The medial rectus muscle is a muscle in the orbit that adducts the eyeball (makes it move inwards).

• As with most of the muscles of the orbit, it is innervated by the inferior division of the oculomotor nerve (Cranial Nerve III).

• Its origin is the anular tendon.

• The superior oblique muscle is a muscle in the orbit that causes the eye to look downwards when it is already directed medially (looking towards the nose).

• It is the only muscle supplied by the trochlear nerve. The superior oblique loops through a pulley like structure (the trochlea) to get the desired movement.

• The inferior oblique muscle is a muscle in the orbit that adducts (medially rotates) and elevates the eyeball (i.e. it makes the eye move inward and upward).

• As with most of the muscles of the orbit, it is innervated by the oculomotor nerve (Cranial Nerve III).

• Its origin is the inferior rim of the orbit, directly below the supraorbital notch. It inserts laterally onto the eyeball, deep to the lateral rectus, by a short flat tendon. It elevates the eye most when it is already adducted.

• In summary, the SIX cardinal directions of GAZE are as follows:

• (OD = right eye; OS = left eye)

• RIGHT & UP: OD = superior rectus, OS = inferior oblique• RIGHT: OD = lateral rectus, OS = medial rectus• RIGHT & DOWN: OD = inferior rectus; OS = superior oblique• LEFT & UP: OD = inferior oblique, OS = superior rectus• LEFT: OD = medial rectus, OS = lateral rectus• LEFT & DOWN: OD = superior oblique, OS = inferior rectus

Normal Findings

• Full conjugate eye movements.• No nystagmus in any direction• No nystagmus : Jerky, oscillatory eye

movements• No Lid lag (when eye move from above to downward)

The Eyes Examination :Inspection Lid lag / hyperthyrodism

Ophthalmoscopic Examination

• Perform direct opthalmoscopy, assess:– red reflex (absence of red reflex suggests an opacity of

the lens, cataract)

– optic cup & disc– retinal blood vessels– retinal background– macula

The Eye

Opthalmoscopic Exam• Patient focus on distant object (dark room)• Both you and the patient should remove glasses if worn but contact

lenses don’t need to be removed• Switch on the scope light and turn the lens disc until you see the large round beam of

white light. Adjust the size of the incident light beam to the size of the pupil.

• Ophthalmoscope should be close to your eyes. Your head and the scope should move together

• Set the lens opening at 0 diopters. With the ophthalmoscope 12-15 inches from the patient's eye. &angle of 15 degrees lateral to the patient’s line of vision

• Check for red reflex and opacities in lens or aqueous.

Opthalmoscopic Exam• While adjusting the diopter setting, approach the patient

more closely and systematically inspect the disc, noting the color, shape, margins and cup-to-disc ratio.

• Rt to Rt…Lt to Lt eyes• Inspect vessels, noting obstruction, arterial/venous ratio. • Note the presence of arterial/venous nicking and arterial

light reflex. • Check background by inspecting for pigmentation,

hemorrhages, exudates.

• Next, try to identify the macula.

Normal Eye Fundus• Disc – margins are sharp – color: yellowish orange to creamy

pink – shape: round or oval – Cup to disc ratio: less than half – Central Cup :yellowish white

• Vessels – AV ratio 3:4 – No AV crossing– arterial light reflex

• Fundus background– No exudates (Yellow spot) or

hemorrhages (red spot)– color : red to purplish

• Macula ((fovea is the center)- macula is located 2.5 disc distance

temporal to dis- Tiny bright reflection (fovea): center - no vessels noted around Macula - it may be slightly pigmented

Features of the Arteries and Veins in the Retina

• Artery: bright light red, smaller than vein, • Vein dark red, larger, inconspicuous or absent---------------------------------------------------------• Detecting papilledema: swelling of the optic disk and anterior

pulging of the physiological cup. Can suggest serious disorder like meningitis, trauma, subarchenoid hemorrhage, mass/lesion

Diabetic Retinopathy

Abnormal results may include• myopia, or nearsightedness, which is the ability to see near

objects better than far objects • hyperopia, or farsightedness, which is the ability to see far

objects better than near objects • presbyopia or an inability to focus on near objects that often

occurs in middle-aged persons • blurred vision (astigmatism)• Color blindness which is an inability to see certain colors • blocked tear duct, or a blockage in the tube that carries tears

away from the eye • cataract or a clouding of the lens in the eye that can cause

vision problems • eye trauma or injury • strabismus an eye movement disorder, also called lazy eye• glaucoma• damage to the optic nerve, blood vessels, or fundus • scratches or defects on the cornea

Abnormal findings/ Eye

• Ptosis:– Dropping of the upper lid

Abnormal findings/ Eye

• Sty:– A painful , tender red infection in a gland at the

margin of the eyelid.

Abnormal findings/ Eye

• Chalazion: – Painless nodule, inside the led

Abnormal findings/ Eye

• Entropion ; an inward turning of the led margin .

• Ectropion ; the margin of the lower lid is turned outward exposing the palpebral conjunctiva

• See page 255