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?

•      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

•      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 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

·        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

•      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 (due to possible foreign body or injury)

•      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

•      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?

•      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

•      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

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