Head and Neck Exam
Lymph Nodes:The major lymph node groups are located along the anterior and posterior aspects of the neck and on the underside of the jaw. If the nodes are quite big, you may be able to see them bulging under the skin, particularly if the enlargement is asymmetric (i.e. it will be more obvious if one side is larger then the other). To palpate, use the pads of all four fingertips as these are the most sensitive parts of your hands. Examine both sides of the head simultaneously, walking your fingers down the area in question while applying steady, gentle pressure. The major groups of lymph nodes as well as the structures that they drain, are listed below. The description of drainage pathways are rough approximations as there is frequently a fair amount of variability and overlap. Nodes are generally examined in the following order: Show
Palpating Anterior Cervical Lymph Nodes
Lymph nodes of the head and neck A number of other lymph node groups exist. However, palpation of these areas is limited to those situations when a problem is identified in that specific region (e.g. the pre-auricular nodes, located in front of the ears, may become inflamed during infections of the external canal of the ear). What are you feeling for? Lymph nodes are part of the immune system. As such, they are most readily palpable when fighting infections. Infections can either originate from the organs that they drain or primarily within the lymph node itself, referred to as lymphadenitis. Infected lymph nodes tend to be:
If an infection remains untreated, the center of the node may become necrotic, resulting in the accumulation of fluid and debris within the structure. This is known as an abscess and feels a bit like a tensely filled balloon or grape (a.k.a. fluctuance). Knowledge of which nodes drain specific areas will help you search efficiently. Following infection, lymph nodes occasionally remain permanently enlarged, though they should be non-tender, small (less the 1 cm), have a rubbery consistency and none of the characteristics described above or below. It is common, for example, to find small, palpable nodes in the submandibular/tonsilar region of otherwise healthy individuals. This likely represents sequelae of past pharyngitis or dental infections. Malignancies may also involve the lymph nodes, either primarily (e.g. lymphoma) or as a site of metastasis. In either case, these nodes are generally:
The location of the lymph node may help to determine the site of malignancy. Diffuse, bilateral involvement suggests a systemic malignancy (e.g. lymphoma) while those limited to a specific anatomic region are more likely associated with a local problem. Enlargement of nodes located only on the right side of the neck in the anterior cervical chain, for example, would be consistent with a squamous cell carcinoma, frequently associated with an intra-oral primary cancer. Cervical Adenopathy: Right anterior cervical adenopathy secondary to metastatic cancer. Cervical Adenopathy: Massive right side cervical adenopathy secondary to metastatic squamous cell cancer originating from this patient's oropharynx. Diffuse upper airway infections (e.g. mononucleosis), systemic infections (e.g. tuberculosis) and inflammatory processes (e.g. sarcoidosis) can all cause lymphadenopathy (i.e. lymph node enlargement). HIV infection can also cause adenopathy in any region of the body, including head/neck, axilla, epitrochlear, inguinal and other areas where there are lymph nodes. In these settings, the findings can be symmetric or asymmetric. Historical information as well findings elsewhere in the body are critical to making these diagnoses. Furthermore, it may take serial examinations over the course of weeks to determine whether a node is truly enlarging, suggestive of malignancy, or responding to therapy/the passage of time and regressing in size, as might occur with other inflammatory processes." The Ear
Otoscope Otoscopy: The otoscope allows you to examine the external canal, the structure that connects the outside world with the middle ear, as well as the ear drum and a few inner ear structures. Proceed as follows:
Auditory Acuity: If the patient does not complain of hearing loss, this part of the exam is omitted. A crude assessment can be performed by asking the patient to close their eyes while you place your fingers a few centimeters from either ear. Rub the finger tips of first one hand and then the other. Make note of any obvious differences in hearing. Alternatively, you can stand behind the patient and whisper a few words in first one ear and then the other. Are they able to repeat the phrases back correctly? Does this seem to be equal on either side? These tests obviously are not very objective. Precise quantification requires sensitive equipment and is usually done by a trained audiologist. Detecting Conductive v. Sensorineural Deficits: As with acuity, these tests would only be performed if the patient complained of hearing loss. Transmission of sound can be broken into two components:
Hearing loss can occur at either level. To determine which is affected, the following tests are performed: Weber: Grasp the 512 Hz tuning fork by its stem and get it to vibrate by either striking the tines against your hand or by "snapping" the ends between your thumb and middle finger. Then place the stem towards the back of the patient's head, on an imaginary line equidistant from either ear. The bones of the skull will transmit this sound to the 8th nerve, which should then be appreciated in both ears equally. Remind the patient that they are trying to detect sound, not the buzzing vibratory sensation from the fork. If there is a conductive deficit (e.g. wax in the external canal), the sound will be heard better in that ear. This is because impaired conduction has prevented any competing sounds from entering the ear via the normal route. You can create a transient conductive hearing loss by putting a finger in one ear. Sound transmitted from the tuning fork will then be heard louder on that side. In the setting of a sensorineural abnormality (e.g. an acoustic neuroma, a tumor arising from the 8th CN), the sound will be best heard in the normal ear. If sound is heard better in one ear it is described as lateralizing to that side. Otherwise, the Weber test is said to be mid-line. Weber Test Rinne: Strike the same tuning fork and place the stem on the mastoid bone, a bony prominence located just behind and below the ear. Bone conduction will allow the sound to be transmitted and appreciated. Instruct the patient to let you know as soon as they can no longer hear the sound. Then place the tines of the still vibrating fork right next to, but not touching, the external canal. They should again be able to hear the sound. This is because, when everything is functioning normally, transmission of sound through air is always better then through bone. This will not be the case if there is a conductive hearing loss (e.g. fluid associated with an infection in the middle ear), which causes bone conduction to be greater then or equal to air. If there is a sensorineural abnormality (e.g. medication induced toxicity to the 8th CN), air conduction should still be better then bone as they will both be equally affected by the deficit. Rinne Test The NoseIn the absence of symptoms, this exam is generally omitted. First check to see if the patient is able to breathe through either nostril effectively. Push on one nostril until it is occluded and have them inhale. Then repeat on the other side. Air should move equally well through each nares. To look in the nose, have the patient tilt their head back. Push up slightly on the tip of the nose with the thumb of your left hand. Place the end of the speculum (it's OK to use the same one from the ear exam) into the nares under direct vision. Now look through the viewing window, noting:
Evaluation of Frontal and Maxillary SinusesMaxillary and Frontal Sinuses The head and face contain a number of sinuses, open cavities that communicate with the upper airway. They function to warm and cleanse air before it travels down to the lungs. They may also help to reduce the total weight of the skull. In normal health, these sinuses cannot be appreciated on examination and cause no symptoms. Inflammatory states, in particular those caused by allergy or infection, produce symptoms and findings that may be detected during examination. Symptoms associated with sinusitis include: nasal congestion, nasal discharge, facial pain, fever, and pain on palpation of the maxillary teeth. The frontal and maxillary sinuses are the two that can be indirectly examined. Examination for sinusitis should include the following:
The Oro-PharynxExposure and good lighting are critical. Head and Neck specialists have head lamps that provide excellent illumination and allow them to use both hands to explore the oral cavity. Most other physicians, however, use an otoscope or flashlight for illumination. A tongue depressor assists with the exploration. The exam should be performed in an orderly fashion as follows:
Right parotid mass. Note enlargement on right compared with left. The Thyroid ExamPrior to palpation, look at the thyroid region. If the gland is quite enlarged, you may actually notice it protruding underneath the skin. To find the thyroid gland, first locate the thyroid cartilage (a.k.a the Adams Apple), which is a mid-line bulge towards the top of the anterior surface of the neck. It's particularly prominent in thin males, sits atop the tracheal rings, and can be seen best when the patient tilts their head backwards. Deviation to one side or the other is usually associated with intra-thoracic pathology. For example, air trapped in one pleural space (known as a pneumothorax) can generate enough pressure so that it collapses the lung on that side, causing mediastinal structures, along with the trachea, to be pushed towards the opposite chest. This deviation may be visible on inspection and can be accentuated by gently placing your finger in the top of the thyroid cartilage and noting its position relative to the midline. The thyroid gland lies approximately 2-3 cm below the thyroid cartilage, on either side of the tracheal rings, which may or may not be apparent on visual inspection. If you're unsure, give the patient a glass of water and have them swallow as you watch this region. Thyroid tissue, along with all of the adjacent structures, will move up and down with swallowing. The normal thyroid is not visible, so it's not worth going through this swallowing exercise if you don't see anything on gross inspection. Location of the ThyroidPalpation: The thyroid can be examined while you stand in front of or behind the patient. Exam from behind the patient is described below:
What causes posterior cervical lymph nodes to swell?The most obvious reason for developing swollen posterior cervical lymph nodes is an infection in or affecting the head region. Lymph node inflammation is often tender to the touch and feels raised. Additional symptoms may include body aches, congestion, and fever.
Why is my lymph node swollen on left side?Swollen lymph nodes usually occur as a result of infection from bacteria or viruses. Rarely, swollen lymph nodes are caused by cancer. Your lymph nodes, also called lymph glands, play a vital role in your body's ability to fight off infections.
What does a swollen posterior cervical lymph node feel like?When the cervical lymph nodes in your neck swell, they aren't usually painful. In some cases, they may be tender to the touch or cause you discomfort. They may feel firm or rubbery, and they may stay in one place or shift around under your skin.
Is it normal for only one side of lymph nodes to swell?A swollen node with a bacterial throat infection is usually just on one side. It can be quite large; over 1 inch (25 mm) across. This is about the size of a quarter. Most often, it's the node that drains the tonsil.
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