Chapter 1 – History and Physical Examination
Marion E. Couch
It is a privilege to be a physician requested to evaluate a person and render an opinion and diagnosis. The importance of an accurate, detailed history cannot be overemphasized because it is the framework on which the otolaryngologist places all available information, building toward an accurate diagnosis and management plan. Without this, the evaluation may be incomplete and the diagnosis flawed. Unnecessary testing may ensue, and, at the minimum, a delay in management may result. In the worst scenario, a misdiagnosis may occur. Therefore, the energy expended in obtaining a complete history is always worthwhile.
In addition to the challenge of obtaining a comprehensive history, the otolaryngologist is faced with examining the complex anatomy of the head and neck region. There are many different examination techniques to learn and much specialized equipment to use. It may take years to master the fundamentals of a complete head and neck examination. Even experienced otolaryngologists are continually modifying and refining their techniques to better examine patients.
Finally, the otolaryngologist should be efficient, and often this means politely directing the questions in the interview to avoid rambling answers from the patients that may contribute little to the history. The same efficiency is helpful when examining patients. The time saved by proficient examination of regions unrelated to the patients’ problem will allow for a more careful and thorough examination of the problem area.
GATHERING A PATIENT HISTORY
Many physicians will mail a detailed and directed questionnaire to their patients before their office visit. This has multiple advantages. First, it enables patients to accurately record the symptoms they are experiencing and to chronicle the history of their problems. In addition, the names of all their medications and the correct dosages and any drug allergies can be listed. Addresses and telephone numbers that are difficult to recall, such as those of their primary care or referring physician, can be listed for later use. Some patients with special communicative disorders, such as those with laryngectomies, tracheostomies, or spastic dysphonia, may appreciate the opportunity to relay information without lengthy verbal discussions. For these reasons, the otolaryngologist is better able to efficiently gather important information even before the patient has arrived in the office. This information also may allow a preliminary differential diagnosis to be formulated in certain patients.
It also is helpful to request that previous medical records pertaining to the patient’s current problem be sent to the office before the visit. The primary care physician, referring physician, patient, or a family member often can assist in obtaining these records. If previous operations have been performed, operative reports can be important sources of information. In addition, pertinent radiographic imaging is helpful to obtain for review. Reports of computed tomography (CT) or magnetic resonance imaging (MRI) scans are valuable but cannot substitute for actual review of the imaging by the otolaryngologist. For head and neck cancer patients, any pathologic slide specimens from past biopsies should be sent to the pathology department for review so that a second opinion may be rendered. This is especially true when patients are referred with an unusual pathologic diagnosis. Finally, laboratory values can provide much information and should be carefully reviewed.
The questionnaire, although valuable, is no substitute for a thoughtful and thorough interview with the patient. The chief complaint should be addressed by determining duration, intensity, location, frequency, factors that make the problem worse or better, any past therapy, and related symptoms. Whether the complaint is vertigo, pain, sinusitis, hearing loss, allergies, or a neck mass, the approach should entail asking many of the same basic questions followed by more specific ones designed to elucidate the full scope of the problem.
A discussion of the patient’s medical history not only leads to a better understanding of the patient, but it often reveals pertinent information to the otolaryngologist. For instance, a patient with an otitis externa who also is diabetic requires a higher level of concern for malignant otitis externa, and this may be reflected in the management plan. If the patient requires surgery, complete knowledge of the patient’s medical problems is necessary before the operative procedure. Easy bruising and prolonged bleeding, pulmonary disease, or coronary artery disease are obvious examples of medical issues that should be addressed before surgery. However, what about the patient with cervical spine stenosis and intermittent limb paresis? Any manipulation of the cervical spine intraoperatively could have serious ramifications. Therefore, it is essential to elicit a complete medical history because requesting the proper preoperative evaluations and consultations can only be done if this information is known.
The surgical history is equally valuable. All the past operations of the head and neck area are important to note, including surgery for past facial trauma, cosmetic facial plastic surgery, otologic surgery, and any head and neck surgery for neoplasm, although full disclosure of all past operations may be critical. For example, the choice of a free flap may depend on whether a patient has had previous abdominal surgery with incisions that would have transected the flap pedicle. If any patient goes to surgery, it is essential to know if a patient has had previous adverse reactions to anesthetic agents or had a difficult intubation.
Obviously, any known drug allergies and side effects are critical to note prominently in the medical chart. True allergies should be distinguished from side effects because an effective antibiotic may be needlessly avoided when the patient has previously experienced common side effects such as gastrointestinal discomfort, which can be safely managed. In addition, all medications and current dosages should be accurately recorded. Often, it is valuable to inquire whether the patient has been compliant with the medication regimen that was prescribed because it is important to consider the doses that the patient actually is receiving. For instance, nasal steroids should be used daily and are not as effective when used intermittently. Therefore, a poor response may be solely a result of subtherapeutic levels of the medication.
After this, it often is advantageous to assess for risk factors associated with certain disease states. Tobacco use is important to note. It is helpful to specifically ask about cigarette, cigar, and chewing tobacco consumption—either current or past use. Patients being assessed for head and neck cancer may deny tobacco use if only asked if they smoke cigarettes, although they may have extensively used cigars or chewed “snuff.” Alcohol consumption also is occasionally difficult to quantitate unless the interviewer asks direct questions regarding frequency, choice of beverage, and duration of use. Recreational drug use should be addressed, as should risk factors for communicable diseases such as the human immunodeficiency virus (HIV) and hepatitis virus. For patients being assessed for hearing loss, major risk factors such as exposure to machinery, loud music, or gunfire should be discussed. Finally, past irradiation (implants, external beam, or by mouth) and dosage (either high- or low-dose) should be ascertained. A history of accidental radiation exposure also is important to document.
The social history should not be overlooked because it may often reveal more occult risk factors for many diseases. For instance, a retired steel worker may have an extensive history of inhaling environmental toxins, whereas a World War II veteran may have noise-induced hearing loss from his or her military service. Family history often is equally revealing, and asking patients questions about their familial history of such conditions as hearing loss, congenital defects, atopy, or cancer may uncover useful information that they had not previously considered.
Finally, a review of systems is part of every comprehensive history. This review includes changes in the patient’s respiratory, neurologic, cardiac, endocrine, psychiatric, gastrointestinal, urogenital, cutaneous skin, or musculoskeletal systems. The otolaryngologist often may derive more insight into the patient’s problem by inquiring about constitutional changes such as weight loss or gain, fatigue, heat or cold intolerance, rashes, and the like ( Box 1–1 ).
It is imperative to develop an approach to the head and neck examination that allows the patient to feel comfortable while the physician performs a complete and comprehensive evaluation. Many of the techniques used by the otolaryngologist, such as fiberoptic nasopharyngolaryngoscopy, may leave a patient feeling alienated if not done correctly, with a sensitivity to the patient’s emotions. Even allowing inspection of one’s oral cavity or nares requires a certain amount of trust by the patient. Thus, it is essential to establish a rapport with a patient before proceeding with the examination. At the same time, the physician should be confident and comfortable with a standard routine examination that allows systematic examination of every patient so that nothing is forgotten or overlooked.
A word of caution is necessary. The head and neck examination should only be done with the examiner wearing gloves and, in most instances, protective eye covering. Universal precautions are mandatory in today’s practice of medicine.
Box 1-1. History
Inquire about chief complaints
Review of systems
Therefore, routine hand-washing and wearing gloves should be incorporated into the examination ritual. This has the added benefit of showing the patient that the examiner is concerned about not transmitting any diseases, which builds trust between the patient and physician.
Much information can be obtained by first assessing the general behavior and appearance of the patient. For instance, the patient’s affect may suggest possible depression, anxiety, or even alcoholic intoxication. Psychotic behavior in the office may be a result of many factors but may indicate profound hypothyroidism in head and neck cancer patients. Astute observation of the patient’s appearance is equally important. Tar-stained fingernails, teeth, or moustache are harbingers for heavy tobacco consumption. Even the gait of patients as they enter or leave the office may reveal information. Neurologic impairments, especially involving the cerebellum, may affect the patient’s ability to navigate into the room.
After assessing the patient’s overall appearance, the face should be analyzed for facial asymmetry by positioning the
TABLE 1-1 — AAQ-HNS facial nerve grading system
Normal facial function at all times
II. Mild dysfunction
Forehead: moderate-to-good function
Eye: complete closure
Mouth: slight asymmetry
III. Moderate dysfunction
Forehead: slight-to-moderate movement
Eye: complete closure with effort
Mouth: slightly weak with maximum effort
IV. Moderately severe dysfunction
Eye: incomplete closure
Mouth: asymmetric with maximum effort
V. Severe dysfunction
Eye: incomplete closure
Mouth: slight movement
VI. Total paralysis
head squarely in front of the examiner. This simple step may yield subtle but important information. For instance, in patients considering facial plastic surgery, a hemifacial microsomia may affect the final outcome, and this should be discussed before the operation. In addition, a paretic facial nerve always is a serious finding that can be detected by observing the tone of the underlying facial musculature and overlying facial skin. Facial wrinkles are more prominent when the facial nerve is functioning. Other maneuvers to assess facial nerve function include having the patient broadly smile, wrinkle the nose, and close the eyes tightly. For patients recovering from facial nerve paralysis, the AAQ-HNS Facial Nerve Grading System is a respected standard for reporting gradations of nerve function ( Table 1–1 ).
The facial skeleton then should be carefully palpated for bony deformities. This is especially true in patients with recent facial trauma. The periorbital rims may be irregular as a result of fractures involving the zygomatic arches or orbital floor. The dorsum of the nose may be displaced as a result of a comminuted nasal fracture. After evaluation of the facial skeleton, the regions overlying the paranasal sinuses may be firmly palpated or tapped for tenderness, which may be present during an episode of sinusitis.
Evaluation of the temporomandibular joint (TMJ) is convenient to perform at this point in the examination. By having the examiner place three fingers over the TMJ region, which is anterior to the external auditory canal, anteromedial dislocation (caused by the action of the lateral pterygoid muscle) or clicking of the joint can be ascertained. The patient should open and close the jaw to assist in evaluating this synovial joint.
Masses in the parotid may be benign or malignant neoplasms of the parotid, cysts, inflammatory masses, or lymph node metastasis from other areas. The tail of the parotid extends to the region lateral and inferior to the angle of the mandible. This is a common site for parotid masses to reside. The parotid–preauricular and retroauricular lymph nodes also should be systematically assessed in every patient. By facing the patient and placing both hands behind the ears before palpating the preauricular nodes, the often-neglected retroauricular nodes will not be missed.
Skin covering the face and neck should be examined, and suspicious lesions should be noted. The external auricles often receive sun exposure and are at risk for developing the skin malignancies such as basal cell and squamous cell carcinomas. The scalp should be examined for hidden skin lesions, such as melanoma, basal cell carcinoma, or squamous cell carcinoma. All moles should be inspected for irregular borders, heterogeneous color, ulcerations, and satellite lesions.
The neck, an integral part of the complete otolaryngology examination, is best approached by palpating it while visualizing the underlying structures ( Fig. 1–1 ). The midline structures such as the trachea and larynx can be easily located and then palpated for deviation or crepitus. If there is a thyroid cartilage fracture, tenderness and crepitus may be present. In thick, short necks, the “signet ring” cricoid cartilage is a good landmark to use for orientation. The hyoid bone can
Figure 1-1 Basic anatomy of the anterior neck. Visualize structures while performing neck examination.
be inspected and palpated by gently rocking it back and forth.
Traveling more inferior in the neck, the thyroid gland, which resides below the cricoid cartilage, should be examined by standing behind the patient and placing both hands on the paratracheal area near the cricoid cartilage. Having the patient swallow or drink a sip of water often helps better delineate the thyroid lobes by having the trachea rise and fall. Pressing firmly in one tracheal groove allows the contents of the other side to be more easily distinguished by gentle palpation. Nodules or cystic structures should be carefully noted and evaluated, often by fine-needle aspiration. Adjacent adenopathy also should be carefully assessed.
After this, palpation of the supraclavicular area, from the paratracheal grooves posteriorly to the sternocleidomastoid muscle to the trapezius muscle, will help detect masses or enlarged lymph nodes, which are worrisome for metastasis from sources such as the abdomen, breast, or lung. Proceeding more superiorly, the area inferior to the angle of the mandible houses the carotid arteries and often has many lymph nodes, either “shoddy” and indistinct or firm. Palpable nodes always should be noted and may need evaluation with either fine-needle aspiration or radiologic imaging when observation is not appropriate. The carotid artery, often mistaken for a prominent node, can be assessed for the presence of bruits. The entire jugulodigastric chain of lymph nodes merits careful inspection by outlining the sternocleidomastoid muscle and palpating the soft tissue anterior and posterior to it. The submandibular and submental regions are palpated by determining the outline of the glands and any masses present. It often is difficult to distinguish masses from the normal architecture of the submandibular gland, and therefore, bimanual palpation of this area using a gloved finger in the floor of the mouth is helpful.
Triangles of the neck
It is helpful to define the neck in terms of triangles when communicating the location of physical findings ( Fig. 1–2 ). The sternocleidomastoid muscle divides the neck into a posterior triangle, whose boundaries are the trapezius, clavicle, and sternocleidomastoid muscles, and an anterior triangle, which is bordered by the sternohyoid, digastric, and sternocleidomastoid muscles. These triangles are further divided into smaller triangles. The posterior triangle houses the supraclavicular and the occipital triangles. The anterior triangle then may be divided into the submandibular, carotid, and muscular triangles.
Lymph node regions
Another classification system for neck masses uses the lymph node regions, which is especially useful for head and neck surgeons when depicting the location of adenopathy ( Fig. 1–3 ). Level IA is the submental triangle, and level IB is the submandibular triangle. The upper third of the jugulodigastric chain is level II, whereas the middle and lower third represent levels III and IV, respectively. More specifically, the jugulodigastric lymph nodes from the skull base to the hyoid bone are located in level II. Level III extends from the hyoid bone to the cricoid cartilage, and level IV includes the lymph nodes located from the cricoid to the clavicle. Level V is the posterior triangle, which includes the spinal accessory and supraclavicular nodes. The prethyroid nodes are contained in level VI, whereas the tracheoesophageal nodes are in level VII. The parotid–preauricular, retroauricular, and suboccipital regions often are designated as the P, R, and S regions.
The postauricular region, which is frequently overlooked, often has many hidden physical findings. For instance, well-healed surgical incisions signify previous otologic procedures have been performed. In children, the postauricular mastoid area may harbor important clues that a mastoiditis with a subperiosteal abscess has developed. The erythema and edema may cause the entire auricle to be pushed down outward, away from the temporal bone, obliterating the postauricular sulcus. Finally, in patients with head trauma, postauricular ecchymosis, or Battle’s sign, suggests that a temporal bone fracture may have occurred.
The area anterior to the pinna, at the root of the helix, may house preauricular pits or sinuses, which may become infected. The external auricles also may reflect abnormalities or congenital malformations, including canal atresia, accessory auricles, microtia, and prominent protruding “bat ears.” The outer ears may have edema with weeping, crusting otorrhea, which may signify an infection is present. Psoriasis of the auricle or external auditory canal with its attendant flaking, dry skin, and edema is another common finding.
Careful inspection of the auricles may reveal conditions that mandate prompt management. For instance, an auricular hematoma, with a hematoma separating the perichondrium from the underlying anterior auricular cartilage, will present as a swollen auricle with distortion of the normal external anatomy. If not surgically drained, a deformed “cauliflower ear” may result. Another important diagnosis is that of carcinoma of the auricle. Because early diagnosis is important, all suspicious lesions or masses should be judiciously biopsied or cultured. A maculopapular rash on the auricle and the external auditory canal in patients with facial nerve paralysis most likely is a result of herpes zoster oticus or Ramsey-Hunt syndrome. Finally, an erythematous painful pinna may represent many entities, such as perichondritis, relapsing polychondritis, Wegener’s granulomatosis, or chronic discoid lupus erythematosus.
Figure 1-2 Triangles of the neck. The anterior triangle is divided from the posterior triangle by the sternocleidomastoid muscle.
Metabolic disorders also may have manifestations that affect the auricles. Patients with gout may have tophus on the pinna that will exude a chalky white substance if squeezed. Ochronosis is an inherited disorder of homogentisic acid that will cause the cartilage of the auricles to blacken. These examples of various diseases and syndromes illustrate the importance of examining the auricles on a routine basis.
External auditory canal
The outer third (approximately 11 mm) of the auditory canal is cartilaginous, and the adnexa of the skin contains many sebaceous and apocrine glands that produce cerumen. Hair follicles also are present. The inner two thirds (approximately 24 mm) of the canal is osseous and has only a thin layer of skin overlying the bone. Cerumen is commonly found accumulating in the canal, often obstructing it. When removing cerumen, remember two points. The canal is well supplied with sensory fibers: CN V3, the auricular branch of CN X, C3, and CN VII. Second, the canal curves in an S-shape toward the nose. To visualize the ear canal, gently grasp the pinna and elevate it upward and backward. This will open the external auditory canal opening and allow atraumatic insertion of the otoscopic speculum. Cerumen impaction may be removed with many techniques, such as careful curetting, gentle suctioning, or irrigation with warm water.
An otitis externa, or “swimmer’s ear,” is a painful condition with an edematous, often weeping external canal. If severe, the entire canal may be so edematous and inflamed that it closes, making inspection of the tympanic membrane difficult. Gently tugging on the auricle is painful for many patients. The periauricular lymph nodes may be tender and enlarged. If the patient is immunocompromised or diabetic, the canal should be carefully inspected for the presence of granulation tissue at the junction of the cartilaginous and bony junction. This may signify that a malignant otitis externa is present, which, as an osteomyelitis of the temporal bone, requires aggressive management, including prompt intravenous antibiotics.
In older patients, atrophy of the external auditory canal skin is frequently seen and may be associated with psoriasis or eczema of the canal. If patients attempt to sooth an itch
Figure 1-3 Lymph node regions of the neck.
with foreign objects such as keys, hair pins, or cotton-tipped swabs, scabs or areas of ecchymosis may be present in the posterior canal wall.
Children are most likely to inset foreign bodies into the ear canal. Although most objects will lodge lateral to the narrowest part of the canal, the isthmus, some will be found in the anterior recess by the tympanic membrane, making it especially difficult to visualize with an otoscope, so have patients turn their head to view this area. In adults, cotton plugs are commonly lodged and often are impacted against the tympanic membrane. In patients of all ages, insects may find their way into the canal. Instilling the canal with alcohol or lidocaine is effective in killing this particularly annoying foreign body. A combination of suctioning, alligator forceps, and irrigation frequently is needed to remove foreign body objects. An operating microscope allows excellent visualization and enables the physician to use both hands to manipulate the instruments needed to remove the object.
Otorrhea is commonly seen in the external auditory canal. The characteristics of the aural discharge may reveal the etiology of the otorrhea. For instance, mucoid drainage is associated with a middle ear chronic suppurative otitis media because only the middle ear has mucus glands. In these patients, a tympanic membrane perforation should be present to allow the mucoid otorrhea to escape. Foul-smelling otorrhea may be caused by chronic suppurative otitis media with a cholesteatoma. Bloody, mucopurulent otorrhea frequently is seen in patients with acute otitis media, trauma, or carcinoma of the ear. Otorrhea with a watery component may signify a cerebrospinal fluid leak or eczema of the canal. Black spores in the otorrhea may be present in a fungal otitis externa caused by Aspergillus species. Gentle suctioning is used to clean the canal and to inspect it thoroughly.
In patients with head trauma, a temporal bone fracture is important to recognize. Bloody otorrhea in conjuction with an external canal laceration or hemotympanium are very serious findings. Longitudinal fractures often involve the external canal. Because longitudinal fractures may be bilateral, careful inspection of both canals is essential.
To view the tympanic membranes, the correct otoscope speculum size is used to allow a seal of the ear canal. With pressure from the pneumatic bulb, the tympanic membrane will move back and forth if the middle ear space is well aerated. Perforations and middle ear effusions are common causes for nonmobile tympanic membranes.
The tympanic membrane is oval, not round, and has a depressed central part called the umbo, wherein the handle of the malleus attaches to the membrane. The lateral process of the malleus is located in the superior anterior region and is seen as a prominent bony point in atelectatic membranes. Superior to this process is the pars flaccida, wherein the tympanic membrane lacks the radial and circular fibers present in the pars tensa, which is the remainder of the ear drum. This superior flaccid area is critical to examine carefully because retraction pockets may develop here, which may develop into cholesteatomas. In congenital cholesteatomas, often diagnosed in young children, the tympanic membrane is intact, and a white mass is seen in the anterior superior quadrant. Acquired cholesteatomas in adults are different in that they often are in the posterior superior quadrant and are associated with retraction pockets, chronic otitis media with purulent otorrhea, and tympanic membrane perforations.
To assess the middle ear for effusions, use the tympanic membrane as a window that allows a view of the middle ear structures ( Fig. 1–4 ). Effusions may be clear (serous), cloudy with infection present, or bloody. When the patient performs a Valsalva maneuver, actual bubbles may form in the effusion.
Tuning fork tests, usually done with a 512-Hz fork, allow one to distinguish between sensorineural and conductive hearing loss ( Table 1–2 ). They also may be used to confirm the audiogram, which may give spurious results because of poor fitting earphones or variations in equipment or personnel. Be sure to conduct all tests in a quiet room without background noise. Also, be certain that the external auditory canal is not blocked with cerumen.
The Weber test is performed by placing the vibrating tuning fork in the center of the patient’s forehead or at the
TABLE 1-2 — Tuning fork testing
Begin with 512-Hz fork, then include 256- and 1024-Hz forks
Place tuning fork in center of patient’s forehead. Ask patient if sound is louder on one side or is heard midline.
“Sound is midline”
“Sound is louder on right”
“Sound is louder on left”
Bone-conducted sound equal in both ears
Unilateral right conductive hearing loss; unilateral left sensorineural hearing loss
Unilateral left conductive hearing loss; unilateral right sensorineural hearing loss
Place tuning fork lateral to ear canal, then place it firmly on mastoid process. Ask patient if sound is louder by canal or on mastoid bone.
“Sound louder when fork by canal”
“Sound louder when fork on mastoid process”
Air conduction louder than bone conduction; normal
Bone conduction louder than air conduction; conductive hearing loss
Air and bone conduction equal
Figure 1-4 The tympanic membrane.
bridge of the nose. If the patient has difficulty with these locations, the mandible or front teeth may be used, however, the patient then should tightly clench his or her teeth. The patient then is asked if the sound is louder in one ear or is heard midline. The sound waves should be transmitted equally well to both ears through the skull bone. A unilateral sensorineural hearing loss will cause the sound to lateralize to the ear with the better cochlear function. However, a unilateral conductive hearing loss will cause the Weber test to lateralize to the side with the conductive loss because the cochlea is intact bilaterally and because bone conduction causes the sound to be better heard in the ear with the conductive loss (because there is less background noise detected through air conduction). Interestingly, a midline Weber result is referred to as “negative.” “Weber right” and “Weber left” refer to the direction the sound lateralized.
To compare air conduction with bone conduction, perform the Rinne test. The 512-Hz tuning fork is placed by the ear canal and then on the mastoid process. The patient determines whether the sound is louder when the tuning fork is by the canal (air conduction) or on the mastoid bone (bone conduction). A “positive test” result is air conduction louder than bone conduction. A conductive hearing loss will make bone conduction louder than air conduction, and this is called “Rinne negative.” When the air and bone conduction are equal, it is called “Rinne equal.”
The Schwabach test compares the patient’s hearing with the examiner’s and uses multiple tuning forks such as the 256-, 512-, 1024-, and 2048-Hz forks. The stem of the vibrating tuning fork is placed on the mastoid process of the patient and then is placed on the mastoid of the physician. This is done, alternating between the two participants, until one can no longer hear the tuning fork. Of course, this test assumes that the examiner has normal hearing. If the patient hears the sound as long as the physician, the result is “Schwabach normal.” If the patient hears the sound longer than the physician, it is called “Schwabach prolonged,” and this may indicate a conductive hearing loss for the patient. If the patient hears the sound for less time, it is called “Schwabach shortened” and is consistent with sensorineural hearing loss for the patient.
The boundaries of the oral cavity extend from the skin–vermillion junction of the lips, hard palate, anterior two thirds of the tongue, buccal membranes, upper and lower alveolar ridge, and retromolar trigone to the floor of the mouth. This region may be best seen by having the otolaryngologist use a well-directed headlight and a tongue depressor
in each gloved hand. The lips should be carefully inspected and may have ulcers present that may be caused by herpes simplex virus, syphilis, or carcinoma. Remember that lip squamous cell carcinoma is more common on the lower lip. The commissures may have fissuring, which is seen in angular stomatitis or cheilosis. When the fissures and cracking are present on the mid-portion of the lips, this may be cheilitis.
The occlusion of the teeth and the general condition of the alveolar ridges, including the gums and teeth, should be noted. The tongue, especially the lateral surfaces where carcinomas are most common, should be inspected for induration or ulcerative lesions. Gently grabbing the anterior tongue with a gauze sponge allows the examiner to move the anterior tongue from side to side. By having the patient lift the tongue toward the hard palate, the floor of mouth and Wharton’s ducts (associated with submandibular glands) can be viewed. Pooling of carcinogens in the saliva on the floor of the mouth has been postulated to cause this area to have a high incidence of carcinoma in the oral cavity. Be sure to palpate the floor of mouth using a bimanual approach with one gloved hand in the mouth.
The buccal membranes should be inspected for white plaques that may represent oral thrush, if easily scraped off with a tongue blade, or leukoplakia, which cannot be removed. More worrisome for a precancerous condition is erythroplakia; therefore, all red lesions and most white lesions should be judiciously biopsied for cancer or carcinoma in situ. While examining the buccal membranes, note the location of the parotid duct, or Stenson’s duct, as it opens near the second upper molar. Small yellow spots in the buccal mucosa are sebaceous glands, commonly referred to as Fordyce spots, and are not abnormal. Aphthous ulcers, or the common canker sore, are painful white ulcers that can be on any part of the mucosa but are commonly present on the buccal membrane.
The hard palate may have a bony outgrowth known as a torus palatinus. These midline bony deformities are benign and should not be biopsied, although growths that are not in the midline should be more carefully evaluated as possible cancerous lesions.
The oropharynx includes the posterior third of the tongue, anterior and posterior tonsillar pillars, the soft palate, the lateral and posterior pharyngeal wall, the soft palate, and the vallecula ( Fig. 1–5 ). It is best visualized using a headlight and two tongue depressors. A dental mirror is instrumental in viewing the vallecula and the posterior pharyngeal wall, which often are obscured. Using a gloved finger to examine the base of tongue or tonsil may reveal indurated areas that may be appropriate for biopsy for neoplasm. The patient should be aware of the possibility that gagging may ensue when this is done. In patients with especially strong gag reflexes, a fiberoptic examination may be necessary to fully assess the base of tongue, posterior pharyngeal wall, and vallecula. By carefully passing the flexible fiberoptic endoscope
Figure 1-5 The oropharynx, which includes the posterior third of the tongue, soft palate, tonsillar pillars (anterior and posterior), lateral and posterior pharyngeal wall, and vallecula.
through the anesthetized nose, the interaction of the soft palate and tongue base during swallowing also may be viewed. The uvula should be inspected because a bifid structure may signify a submucosal cleft palate is present. In addition, an inflamed large uvula may mean the uvula is traumatized during the night if the patient snores heavily. Small carcinomas or papilloma lesions also may be present, so careful palpation may be indicated.
The size of the tonsils usually is denoted as 1+, 2+, 3+, or 4+ (for “kissing tonsils” that meet in the midline). The tonsils and the base of tongue may contribute to upper airway obstruction, especially if the soft palate and uvula extend posteriorly. Therefore, the oropharyngeal aperture should be carefully assessed in each patient. Tonsillitis, caused by either bacterial or viral sources such as group A streptococcus or mononucleosis, often presents with an exudate covering the cryptic tonsils. A culture of the exudate should be taken because of the importance of diagnosing and managing a streptococcal tonsillitis. Tonsilliths are a common cause for a foreign body sensation in the back of the throat. These yellow or white concretions in the tonsillar crypts are not caused by food trapping or infection, but they often cause the patient to have halitosis and should be removed with a cotton-tipped swab.
Larynx and hypopharynx
The larynx often is subdivided into the supraglottis, glottis, and subglottis. The supraglottic area includes the epiglottis, the aryepiglottic folds, the false vocal cords, and the ventricles. The inferior floor of the ventricle, the true vocal folds, and the arytenoids comprise the glottis. The subglottis region generally is considered to begin 5 to 10 mm below the free edge of the true vocal fold and to extend to the inferior margin of the cricoid cartilage, although this is somewhat controversial ( Fig. 1–6 ).
The hypopharynx can be challenging to understand. It extends from the superior edge of the hyoid bone to the inferior aspect of the cricoid cartilage by the cricopharyngeus muscle. It connects the oropharynx with the esophagus. Three areas comprise this region: the pyriform sinuses, posterior hypopharyngeal wall, and the postcricoid area. This area, rich in lymphatics, may harbor tumors that often are detected only in an advanced stage. Thus, early detection of these relatively “silent” carcinomas is important and should not be missed.
The examiner should not only detect anatomic abnormalities but should observe how the larynx and hypopharynx are functioning to allow the patient to have adequate airway, vocalization, and swallow function. It is not enough to survey the larynx for lesions and assess the true vocal fold function. For example, the patient with a normal-appearing larynx may have decreased laryngeal sensation with resultant aspiration and may need further diagnostic and therapeutic evaluation. Therefore, important information can be obtained if the physician carefully assesses the anatomic and functional aspects of this complex area.
Figure 1-6 The larynx.
Correct positioning of patients increases their comfort while maximizing the examiner’s view of the larynx. The legs should be uncrossed and placed firmly on the footrest. The back should be straight with the hips planted firmly against the chair. Patients, while leaning slightly forward from the waist, should place their chin upward so that the examiner’s light source is illuminating the oropharynx well. After discussing the examination procedure with the patient, the patient’s tongue is pulled forward by the examiner, who uses a gauze sponge between the thumb and index finger. This allows the physician’s long middle finger to retract the patient’s upper lip superiorly. A warm dental mirror (to prevent fogging) is placed in the oropharynx and elevates the uvula and soft palate to view the larynx ( Fig. 1–7 ). The patient with a strong gag reflex may benefit from a small spray of local anesthetic to help suppress the reflex.
There are some maneuvers that will allow better visualization of the larynx and its related structures. Panting, quiet breathing, and phonating with a high-pitched E aid in assessing true vocal fold function.
The epiglottis should be crisp and whitish. An erythematous, edematous epiglottis may signify epiglottitis, a serious infection or inflammation that mandates consideration of airway control. The petiole of the epiglottis is a peaked structure on the laryngeal surface of the epiglottis above the anterior commissure of the true vocal folds. It may be confused for a cyst or mass but is a normal prominence. Irregular
Figure 1-7 The laryngeal examination.
mucosal lesions may be carcinomas and require further evaluation.
In the posterior glottis, movement of the arytenoids allows determination of true vocal fold mobility. The interarytenoid mucosa may be edematous or erythematous, sometimes representing gastroesophageal reflux laryngitis. The mucosa over the arytenoids may be erythematous as a result of rheumatoid arthritis or as a result of recent intubation trauma. Posterior glottic webs or scars also may be present.
The true vocal folds should have translucent white, crisp borders that meet each other. Edema of the folds that extends for the entire fold length often is caused by Reinke’s edema, seen in tobacco users. Actual polypoid degeneration of the vocal cord with obstructing polyps may occasionally be seen in patients and may be a result of tobacco use or hypothyroidism. Ulcerative or exophytic lesions deserve further investigation, usually requiring operative direct laryngoscopy. True vocal fold paralysis and subtle gaps present between the folds during cord adduction should be noted.
During abduction of the cords, the subglottic area may be viewed. A prominent cricoid cartilage, seen inferiorly to the anterior commissure, may be mistaken for a subglottic stenosis. It is difficult to fully inspect the subglottic area in the office setting. Any concerns about subglottic inflammatory swelling, masses, or stenosis should be addressed in an operative setting or with radiographic imaging.
Perhaps the best technique to evaluate the function of the larynx uses the flexible fiberoptic nasopharyngolaryngoscope. In conjunction with a strong light source, this allows a more complete evaluation of the structures of the larynx than a mirror examination.
A topical decongestant and anesthetic spray usually is applied to the nares, and the patient is asked to gently sniff these nose sprays. One percent pontocaine and 2% lidocaine are commonly used as topical anesthetics. Another way to administer anesthesia is to carefully apply a viscous 2% lidocaine solution to the nares with a cotton-tipped applicator. It is important to allow time for these topical agents to anesthetize the nasal mucosa, and while the physician is waiting, the scope can be prepared. The focus ring is used to get the brightest possible image. Often there is a small amount of residue at the end of the fiberoptic scope, and this can be carefully removed using either a pencil eraser or an alcohol swab. If the image is not clear when the scope is out of the nose, it will not allow for a useful image when the fiberoptic scope has been passed through the nares. Once the best possible focus has been obtained, a small amount of water-soluble lubricant should be applied approximately 1 cm from the tip of the scope. This is to prevent breakage of the fiberoptic component of the scope while it is passed through the nose.
The laryngoscope then is gently passed along the floor of the nose, and with the instrument tip held above the epiglottis, the larynx may be viewed. Pooling of secretions in the pyriform sinuses is abnormal and is common in patients with decreased laryngeal sensation, neurologic impairment, or tumors. Saliva freely flowing in and out of the true cords is another indication of decreased laryngeal function. In some patients, having patients inhale and hold their breath often aids in viewing the pyriform sinuses. Asking the patient to cough and swallow and then viewing the residual saliva or phlegm also is helpful. The flexible fiberoptic examination enables the patient to freely phonate, unlike with the mirror examination, and the true vocal folds may be assessed by moving the instrument tip into the laryngeal vestibule for closer inspection.
Rigid telescopic examination with 70°, 90°, and 110° telescopes is performed in a similar fashion to the mirror examination. It permits photographic documentation of the laryngeal examination. In patients with trismus, this is better tolerated than the mirror examination, and a minimal amount of local anesthetic usually is necessary.
Anterior rhinoscopy, using a headlight and nasal speculum allows assessment of the nasal septum and inferior turbinates. The speculum should be directed laterally to avoid touching the sensitive septum with the metal edges. The point wherein numerous small branches of the external and internal carotid arteries meet, or Kesselbach’s plexus, is the most common site for epistaxis; prominent vessels in this area should be noted. Anterior septal deviations and bony spurs often are evident. The characteristics of the mucosa of the inferior turbinate may range from the boggy, edematous, pale mucosa seen in those with allergic rhinitis to the erythematous, edematous mucosa seen in those with sinusitis.
Rhinorrhea often reveals important clinical information. Clear mucus often is associated with allergic rhinitis or chronic vasomotor rhinitis. Yellow or green mucopurulence is common with sinusitis. Clear watery rhinorrhea may represent spinal fluid and may indicate a cerebrospinal fluid leak.
Nasal endoscopy using rigid endoscopes allows thorough examination of even the most posterior portions of the nasal cavity. After applying a local anesthetic to the nares, either lidocaine or pontocaine spray or topical 4% cocaine, the rigid 0° endoscope may be passed into the nose along the floor of the nasal vault. The septum, inferior turbinate, and eustachian tube orifices in the nasopharynx may be seen this way. Often, at this time, it is necessary to spray a decongestant to shrink the nasal mucosa. It is helpful to attempt to view the nasal anatomy in the native state and after the decongestant so that the effect of the decongestant may be seen. After inspecting both sides, the endoscope is placed above the inferior turbinate to view the middle turbinate. Accessory ostia from the maxillary sinus often are present, especially in patients with chronic sinusitis. These openings into the lateral nasal wall often are mistaken for the true maxillary ostium.
The nasopharynx extends from the skull base to the soft palate. This is a challenging area to examine, but with the available technology, there are many ways to approach this region. The technique used often will depend on the anatomy of the patient. In the patient with a high posterior soft palate and small tongue base, an otolaryngologist with a headlight may use a small dental mirror to visualize the nasopharynx. By having the patient sit upright in the chair, the physician may firmly pull the tongue forward while opening the mouth to place the mirror just posterior to the soft palate. In a manner analogous to that used to view the larynx with a mirror, the structures in the nasopharynx will be seen when the mirror is oriented upward.
Another method uses a fiberoptic nasopharyngoscope, which allows excellent visualization of this area. After anesthetizing the nares with either topical cocaine (on pledgets) or applying lidocaine spray, many otolaryngologists will spray the nares with a decongestant. The flexible fiberoptic scope then is gently passed along the floor of the nostril beneath the inferior turbinate. The eustachian tube orifice, torus tubarius, and fossa of Rosenmueller should be inspected on each side. This may be accomplished by using the hand control to turn the tip of the scope from side to side. The midline also should be inspected for any masses, ulcerations, or bleeding areas. Rigid endoscopes offer good visualization also, although the ability to view both sides of the nasopharynx often means passing the endoscope through each nostril. The endoscopes have various angles, such as 70°, 90°, and 110°.
Arguably, the best view of all may be obtained using a 90° rigid scope in the oropharynx. By advancing the rigid scope through the mouth and by placing the beveled edge posterior to the soft palate, the nasopharynx may be seen in its entirety. Both sides of the nasopharynx may be compared for symmetry using this technique.
Whereas children will have adenoid tissue present, adults should not have much adenoid tissue remaining in this area. Thus, adenoid tissue should not be a cause of nasal or eustachian tube obstruction in adults. One possible exception is patients with HIV infections, who may manifest adenoid hypertrophy as part of their disease. Nonetheless, adults with an otitis media, especially unilateral in nature, should have their nasopharynx inspected for possible nasopharyngeal masses. If present, it is important to diagnose nasopharyngeal carcinomas, which are most common lateral to the eustachian tube orifice in the fossa of Rosenmueller. In young male patients, nasopharyngeal angiofibromas are locally aggressive, but histologically benign masses that are most commonly present in the posterior choana or nasopharynx. These masses should not be missed. Another malignancy to consider is non-Hodgkin’s lymphoma. Cysts in the superior portion of the nasopharynx may represent a benign Tornwaldt cyst or a malignant craniopharyngioma.
TABLE 1-3 — Neurologic examination
Sense of smell to several substances
Do not use ammonia (common chemical sense caused by CN V stimulation)
Inspect optic fundi
Extraocular movements in six fields of gaze
Pupillary reaction to light
Palpate temporal and masseter muscles
Patient should clench teeth
Test forehead, cheeks, jaw for pain, temperature and light (cotton) touch
Corneal reflex (blinking in response to cotton touching the cornea)
Near reaction to light
Ptosis of upper eyelids
Symmetry of face in repose
Raise eyebrows, frown, close eyes tightly, smile, puff out cheeks
Auditory—Tuning fork tests for hearing
Vestibular—Nystagmus on lateral gaze; Hallpike-Dix test; headshaking; Caloric testing; Frenzel lenses
True vocal cord mobility
Gag reflex (CN IX or X)
Movement of soft palate and pharynx
Shrug shoulders against examiner’s hand (trapezius muscle)
Turn head against examiner’s hand (sternocleidomastoid muscle)
Stick tongue out
Tongue deviates toward side of lesion
Tongue atrophy, fasciculations
Table 1–3 outlines the basics of a neurologic examination appropriate for most head and neck patients. Certainly, patients presenting with vertigo or disequilibrium require a highly specialized neurologic examination, but that is beyond the scope of this chapter. Much valuable clinical information can be obtained with an evaluation of the cranial nerves.
This chapter serves as an outline for approaching the head and neck examination. There are many ways to perform the examination and to take the patient’s history. This chapter is not meant as an exhaustive review of all the examination techniques available, and the order in which the head and neck regions are examined can be changed to suit the physician. Remember to be consistently thorough with each patient. Developing a competently performed, routine examination increases the probability of discovering important clinical information.