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Head & Neck Examination

Dr Irfan AhmadResident, Radiation Oncology

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The major areas comprising this region are:

Head, face & EarSalivary GlandsNose & SinusesOral CavityNasopharynxOropharynxLarynx & LaryngopharynxNeck

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Setting up the examination

Patient positioningInstruments required:

Bulls eye lampHead mirrorTongue depressorsNasal speculum(Thudicum/Vienna)Posterior nasal mirrorLaryngeal mirror

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Head, Face & Ear ExaminationHead & Face

SymptomatologyLumoUlcer

Ear SymptomatologyHearing lossTinnitusEar dischargeEarache Swelling Others(Deformity/ Dizziness/ Itching)

Examn of Mass & Ulcer

Ear Examn (+ Functional):PinnaEAM(+/- Speculum)TMMiddle ear(when TM -)MastoidEustachian Tube(when TM- & Posterior Rhinoscopy)Facial nerve

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Nose & Paranasal Sinuses Examination

Symptomatology:ObstructionDischargeEpistaxisHeadache/facial painLumpChange in voicePND

Parts of Nasal Examn :External nose Examn

Vestibule Examn

Anterior RhinoscopyPosterior RhinoscopyFunctional Examn

Parts of Sinus Examn :Maxillary/ Frontal/ EthmoidSphenoid

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Nasopharynx Examination

Symptomatology:Nasal ObstructionEpistaxisLump (in Neck)DeafnessPND

Parts of Examn :Anterior RhinoscopyPosterior RhinoscopyCN 2-12(m.c. 9-11)Neck Node Examn

OthersDigitalEndoscopyRetraction of structures(GA/LA)

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Oral cavity ExaminationSymptomatology:

PainTrismusLesion(Lump/Ulcer) Dysguesia Xerostomia/ Excess salivation

Parts of Examn :Inspection & palpation of:

LipsTeeth & gingivaRetromolar trigoneBuccal mucosaFloor of mouth Hard palateAnterior 2/3rd of tongue

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Oropharynx ExaminationSymptomatology:

OdynophagiaDysphagiaChange in voiceHalitosisEaracheSore throatHearing lossSnoring

Parts of Examn :Inspection (& palpation) of:

Tonsils & PillarsBase of Tongue(IDL)Soft PalatePosterior pharyngeal wall

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Larynx & Laryngopharynx Examination

Symptomatology:Lump (in neck)DysphagiaPain in throatRespiratory obstructionChange in voiceRepetitive clearing of throatCough(+/-Sputum)

Parts of Examn :External Examn of LarynxIndirect LaryngoscopyAssessment of Cervical lymph nodesOthers:

Flexible/Rigid fibre optic endoscopyVoice assessment

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Neck ExaminationSymptomatology:

Lump(m.c. Nodes)Pain

Parts of Examn :Inspection & palpation of:

SkinNeck NodesAny other mass besides nodes

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Examination of a MassGeneral (CC/IoF)Local:

InspectionLocation/ Number/ Color/ Surface/ Overlying skin/ ShapeSize/ Edge/ PulsatilityPressure effectMovement with

• Respiration• Swallowing• Protrusion of tongue

(Abdominal Swellings –Peristaltic movement)(Swelling connected to cavity – Ab/Pl/ Sp/ Cr) Cough Impulse)

Local:

PalpationTemperature/ TendernessSize/ Shape/ Surface/ Extent/ Edge/ ConsistencyFixation to overlying skin & underlying structuresFluctuationTranslucencyReducibility & compressibilityPulsatilityFluid thrillCough impulse

Regional Lymph NodesPercussion/ Auscultation

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Examination of an UlcerGeneralLocal:

InspectionLocation/ NumberShape/ SizeEdgeFloorDischargeSurrounding area(Peripheral ulcer –Rest of limb)

PalpationTendernessMargin/ Edge BaseDepthBleedingRelation to underlying structuresSurrounding skin

Regional Lymph Nodes(Peripheral Ulcer –vascular insufficiency + nerve lesions)

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Oral Cavity ExaminationOn Inspection:

TrismusDental Hygiene/ Edentulous/ CariesTongue protrusionUlcer/ MassDiscoloration

Look at the following structures:Lips, Teeth, Gingiva, Ant 2/3rd of tongue, Floor of mouth(Ant + Lat), Buccal Mucosa, Hard Palate & Retromolar Trigone

Palpation of all lesions of the oral cavity + Tongue + Bimanual Examination

14Oropharynx Exam

15BOT, pyriform

sinus are not shown in this diagrammatic representation

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Indirect LaryngoscopyPositioning & methodAdduction – AaAdduction & Tension – EeeAbduction – Deep InspirationStructures seen:

EpiG, AE folds, Arytenoids, Cuneiform/ corniculate, ventricular bands, ventricles, True cords, Ant commisure, Post commisure, Subglottis, Tracheal ringsPyriform fossae, post cricoid region, post wall of laryngopharynxBOT, lingual tonsils, valleculae, medial/ lateral glossoepiglottic fold

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Examination of Neck Nodes

Inspection of neck, followed by palpation.•

C Technique

for IJV nodes•Bimanual for Submental & Submandibular nodes

Levels of Lymph node in the neck

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Thank you

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Terms associated with an Ulcer

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Ulcer Edge

Undermined edge

Punched out edge

Sloping edge

Raised edge

Rolled out edge

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AJCC Nodal ClassificationNX Nodes cannot be assessed N0 No lymph node metastasis N1 Single ipsilateral lymph node, <3 cm N2

N2A Single ipsilateral lymph node >3 cm but not >6 cm N2B Multiple ipsilateral lymph nodes, none >6 cm N2C Bilateral or contralateral lymph nodes, none >6 cm

N3 Metastasis in a lymph node >6 cm

(NPC)

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AJCC Nodal Classification for NPCNX Nodes cannot be assessed N0 No regional lymph node metastasis N1 Unilateral node(s) <6 cm above the supraclavicular fossa N2 Bilateral node(s) <6 cm above the supraclavicular fossa N3 Metastasis in lymph node(s)

N3a >6 cm N3b Extension to the supraclavicular fossae

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