Transcription
Hello. Welcome to this video where I will demonstrate how to properly perform a head and neck physical exam.
The inspection process of your patient should begin at the first site where you will have the opportunity to appraise your patient's general appearance and locomotion. During the medical history interview, you can evaluate your patient from a cognitivist endpoint; for example, if the patient can answer your questions accurately. During this time, you can also assess your patient from a neurological standpoint: if the patient is alert and oriented to person, place, and time, or if the patient has any neurological deficiencies like facial palsy, any facial asymmetry, or obvious skin lesions. Before you start to perform the head and neck exam, make sure you have recorded all the pertinent vital signs.
A comprehensive head and neck examination should be performed systematically to minimize oversights. For the head and neck examination, place your patient in a reclining position and follow a logical sequence, starting from top to bottom. Start the exam by inspecting your patient's head, palpating the skull searching for possible lesions, and checking the hair. Continue your exam by placing your fingers on both sides of the head to palpate the temporalis muscle. The temporalis muscle is a bilateral masticatory muscle; it extends posteriorly and covers a large area of the head. You can assess it through firm palpation. Asking your patient to clench will help you to localize the anterior portion of the temporalis muscle. During the temporalis palpation, you can ask your patient if they feel any pain or discomfort.
Continue your exam by assessing the TMJ. Place your fingers in the preauricular area to evaluate the TMJ capsule. Apply light pressure and ask the patient if they have any pain or discomfort. Then, ask your patient to slowly open and close their mouth three times while you look for limitations in the range of motion, deviations, or deflections. Also, during this maneuver, you can hear the TMJ clicking, popping, or crepitus. Continue going down to assess the masseter muscle. The masseter muscle is another masticatory muscle that we can assess through palpation. Asking your patient to clench will help you to localize the superficial masseter muscle.
The neck examination follows this sequence: turn your patient's head to the left. Palpate the sternocleidomastoid muscle. Identifying the sternocleidomastoid muscle will help you to localize the superficial cervical lymph nodes that lie posterior to the sternocleidomastoid muscle and the anterior cervical lymph nodes that lie anterior to the sternocleidomastoid muscle. You can also grab the muscle and ask your patient for pain or discomfort. While the patient is in this position, you can also palpate the occipital and mastoid lymph nodes and inspect the posterior auricular area, looking for any lesions that could be hidden. To finish, do a quick palpation of the muscles of the neck and repeat the same process on the contralateral side.
Continue the examination by localizing the laryngeal prominence of the thyroid cartilage, also known as Adam's apple, that is typically more prominent in males than females. Bilaterally, in a butterfly shape, you will find the thyroid gland. You can move the larynx side to side and also palpate the thyroid gland, searching for enlargement or nodules. You can ask your patient to swallow, and you should see a uniform up-and-down movement of all neck structures.
The palpation of the submandibular nodes follows this approach: from behind the patient's head, identify the inferior border of the body of the mandible and place your fingers in the submandibular space. Lower the chin and gently but firmly press the skin of the submandibular region against the mandible and roll the tissue bilaterally under the inferior border of the body of the mandible. The submandibular lymph nodes are the only lymph nodes in the head and neck region that you can typically palpate. As a normal finding, they should feel soft, movable, non-tender, and less than one centimeter.
To complete the intraoral exam, pay attention to the nasolabial and labiomental groups. The intraoral tissue exam begins with a lip examination. First, note the color, texture, and the surface of the open lips. Note that at the corners of the mouth, the labial commissures, persistent fissures are identified. Identify the tuberculum labii superioris, a bulbous enlargement projecting inferiorly in the center of the upper lip. The lips are transition zones between the skin and mucosa. The red surface of the lips is often referred to as the vermilion, measuring a centimeter or wider. The vermilion is characterized by blood vessels very near to the surface and the lack of sebaceous glands, which makes the area susceptible to drying. Look for changes in color, texture, or surface integrity; some of the first signs of lip cancer. Grasp the lip and palpate to determine variations that exist in the consistency of the tissue. With the help of a mirror, stretch the cheek and inspect the whole surface of the buccal mucosa. At the level of the maxillary second molar, you can see the opening of the parotid duct at the parotid papilla. Also, some patients might have Linea Alba, a horizontal ridge of keratinized tissue extending along the line of occlusion of the teeth. It is very common to find tiny yellowish-white spots that sometimes occur in clusters; these formations are known as Fordyce granules and represent ectopic sebaceous glands.
In your transition to the other side, check the oral vestibule, a U-shaped, cleft-like space bounded by the lips (labial vestibule) and cheeks (buccal vestibule) externally and by the teeth, gums, and alveolar process internally. After the visual inspection, palpate the maxillary and mandibular vestibules, searching for changes in the topography or consistency of the vestibule that could indicate the presence of pathology. Then, direct your attention to the mucosa of the labial and buccal portions of the oral vestibule. Note the fold of mucous membrane, the lip frenum, which attaches the lips to the alveolar process.
The inspection of the palate follows, using a mirror for indirect vision and lighting, visualize the entire palate. Note the mucosa of the hard palate is typically pale pink, resembling gingiva. Palpate over the hard palate with your index finger. Locate the thin, light line marking the midline of the palate; this is the palatine raphe and is sometimes elevated, especially anteriorly. Locate on the mucosal surface of the hard palate a series of irregular ridges called transverse palatine folds or palatine rugae. Find a small, round elevation, the incisive papilla, immediately posterior to the maxillary central incisors. Verify that the lateral aspects of the hard palate are softer and more compressible than the one near to the midline, especially posteriorly where we can find the greater palatine foramen on either side of the palatine raphe. Near to the posterior border of the hard palate, look for a shallow indentation in the palatine surface called the palatine fovea, into which ducts of some of the palatine glands empty. The soft palate is covered by a thin, darker red mucosa, and you can clinically differentiate it from the hard palate. Locate the vibrating line by having the patient say "ah". Use the mirror to gently but firmly depress the tongue and, while having the patient saying "ah", you can, in a few seconds, inspect the oropharynx. Identify the uvula, projecting posteriorly and inferiorly in the middle of the free border of the soft palate. Verify that the uvula hangs in the middle, addressed. Identify the palatoglossal arches that mark the actual boundary between the mouth and the pharynx. Behind the palatoglossal arches, you can localize the palatopharyngeal arches. These three structures create the tonsillar fossa that contains the palatine tonsils. Then, grab a strip of gauze around the anterior 1/3 of the tonsil and hold it so you can manually move it. Pull the tongue gently to one side to better visualize the entire lateral border. With your free hand, palpate along the entire lateral border and the dorsal surface while holding the tonsil with the gauze. Use the mirror to visualize the posterior ventral tongue and the floor of the mouth to examine the floor of the mouth. As the patient elevates the tip of the tongue up to the roof of their mouth, identify the lingual frenulum, a thin median mucosal fold by which the undersurface of the free portion of the tongue is anchored to the floor of the mouth. On either side of the frenum, near its attachment to the floor of the mouth, locate the sublingual carunculae, a small conical projection with an opening at its apex that represents the opening of the submandibular salivary gland. Use a bimanual technique to palpate the floor of the mouth with one finger in the mouth pressing against the finger of the other hand on the chin. Distinguish its most substantial component, the mylohyoid muscle. Move your fingers along the attachment of this muscle to the inner surface of the mandible.
A thorough oral examination concludes with the evaluation of the dentition, including the supporting structures and the analysis of the occlusion. All findings should be recorded in your medical history. Have in mind that every patient is different and they will present with variations of normals that you will learn how to identify and document. With a little bit of practice and patience, you will master the technique.