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Transillumination of frontal sinus. Light is placed under supraorbital rim and transillumination observed through frontal bone.
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Evaluation of the head and neck area involves close attention to details of history and symptoms, intricate physical examination, and proper use of specialty equipment.
Begin by asking about the nose and paranasal sinuses. The examiner should inquire about the presence and duration of trauma, nosebleeds (Chapter 124), drainage, facial aching, congestion, or previous surgery. The type and severity of trauma, a description of the type of drainage, and the degree of pain or swelling should be carefully noted. Associated congestion in the nose and records of all previous nasal or head and neck surgery should be recorded. Frequent occurrence of colds, hay fever reactions, and seasonal exacerbation of these problems should be recorded. Snoring, the use of intranasal drugs such as cocaine or crack, or prolonged use of nasal sprays and the intake of other decongestant medications should be documented. Frequent redness or swelling of the eyes should be noted also.
Next consider the oral cavity and salivary glands. The examiner should inquire about the presence and duration of the following lesions in and about the mouth and lips: ulcers or canker sores, tender gums or painful teeth, xerostomia (dry mouth), fissures at the corner of the mouth or the tongue, and the presence of blood in saliva. The patient should be asked about tongue soreness, recent dental work, difficulty chewing, excess saliva or thick saliva, the chronic use of tobacco, and unusual habits such as bruxism or nocturnal grinding of the teeth. The patient should be asked about the possibility of previous swelling or tenderness under the jaw, in the preauricular area, in the palate or on the tongue, or any limited or painful jaw motions.
For the jaw and temporomandibular joints, a history should be taken to document the presence and duration of the following: trauma, braces or orthodontic treatment, clicking or crunching sounds when opening the mouth, preauricular swelling, tenderness to palpation, teeth grinding at night, frequent clenching of teeth during the day, or pain or discomfort into the temple or down the side of the neck. The patient should also be asked about ringing in the ear or tinnitus, associated sensations of dizziness or unsteadiness, and the presence of ear fullness. The use of dentures or bridges should be documented, and the patient's history concerning excision of third molars (wisdom teeth) or other extractions should be documented.
For the pharynx, larynx, and thyroid gland, the examiner should inquire about the presence and duration of sore throats and previous antibiotic treatment for pharyngitis or mouth ulcers. Questions should be asked about difficulty swallowing, the presence of gland or node enlargement in the neck, the presence of hoarseness (Chapter 125), or the presence of blood in the sputum (hemoptysis). Occupational exposures to chemicals, dust, or various gases should be documented. Any known respiratory allergens should be recorded. Tobacco use should be documented, and the number of years of usage recorded. Unusual use of the voice, such as professional singing or talking consistently above a noisy environment, should be noted. The presence of an irritative cough, tenderness or fullness under the collar, or consistent clearing of the throat should be documented. The patient should be asked about pain on neck motion. The regular use of any prescription drugs should be recorded. Because almost one-third of AIDS patients present with head and neck disorders, any history of risk factors for the disease should be investigated (high-risk sexual practices, use of intravenous drugs with shared needles, blood transfusions).
In collecting information about problems involving the face, the patient should be asked about discomfort in the cheek or forehead, unusual pains following dental procedures, or unusual sensitivity to sunlight. Inquiries should be made about prolonged occupational exposures to sunlight, chemicals, or dust. Patients should be asked if they have used protective hats or masks when around these substances. Questions about the severity of acne in adolescence or recurrent skin infections should be noted. The patient should be asked about visual disturbances related to sagging eyelid or the presence of any double vision, which indicates obstruction of vision.
For evaluation of the ears and hearing, the patient should be asked about awareness of decrease in conversational hearing, and the effect that background noise has upon hearing (Chapter 120). The history of childhood ear disease should be documented along with head, facial, or ear trauma, exposure to ototoxic drugs, previous ear surgery, or ear treatment, and the presence of any severe febrile ear illnesses during childhood. A careful family history for hearing impairment, the use of hearing aids, or known ear surgery should be documented. The patient should be asked about recent respiratory infections or allergy, and medical treatment for severe allergy should be recorded. Questions about ear drainage or discharge, or the presence of excessive wax, should be asked. An occupational and recreational history should be taken, particularly relating to exposure of the patient to excessive noise. The quality, duration, and type of noise should be documented, and the patient's hunting experience or other exposure to gunfire should be recorded. The frequency of aircraft exposure or scuba diving needs to be documented.
Symptoms related to the ear such as ringing in the ear, or tinnitus (Chapter 121), are very common, and specific questions should be asked about duration, intensity, unilateral or bilateral presence, and pulsating or throbbing quality. Fullness in the ear should be documented, and balance disorders or vertigo require particular elaboration (Chapter 123). Frequent probing of the ear for wax removal or itching, or the placement of foreign bodies in the ear, should be documented. The presence of persistent pain in the ear, or otalgia (Chapter 122), or knowledge about drum perforations in the past, is needed. Questions relating to unusual sensitivity to sudden or loud sounds, particularly those associated with or related to other ear symptoms such as tinnitus, vertigo, fullness, or fluctuant hearing loss, need to be recorded. Intermittent, changing, or fluctuant hearing loss may be present.
| Metal or plastic nasal speculum |
| Curved transilluminator on battery handle |
| Disposable wooden tongue depressors |
| Decongestant sprays, such as oxymetazoline or 0.5% neosynephrine |
| Sterile cotton swabs for culture |
| Rubber gloves (nonsterile) |
| Penlight, electric or fiberoptic headlight |
| No. 5 laryngeal mirror (mirror warmer or hot water) |
| Standard wax curette (buck curette) |
| Metal ear syringe or standard 50 cc plastic syringe |
| Standard plastic emesis basin |
| Small thin wire applicator with tufts of cotton |
| Standard electric otoscope with closed lens attachment to permit pneumatic movement of the eardrum with a rubber bulb |
| Ear speculae of various sizes |
| Hydrogen peroxide or aqueous zephiran to dissolve wax |
| 256 Hz tuning fork |
| Ancillary diagnostic equipment |
| Electric audiometer |
| Impedance bridge |
| X-ray equipment to permit routine CT and MRI view of the head and neck area |
| Fiberoptic nasopharyngoscope |
| Nose and paranasal sinuses |
| Oral cavity and salivary glands |
| Jaw and temporomandibular joints |
| Pharynx. larynx, and thyroid glands |
| The face |
Ears and hearing
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Transillumination of frontal sinus. Light is placed under supraorbital rim and transillumination observed through frontal bone.
Transillumination of maxillary sinus. The light is placed against the cheek and transillumination observed through the open mouth.
and 119.2). Some clinics have fiberoptic nasopharyngoscopes for examination of the sinus ostia and nasopharynx, and it may be necessary to send the patient for screening sinus x-rays. Sinus examinations should always be done in a darkened area, and the use of a decongestant spray such as oxymetazolin or 0.5% neosynephrine is encouraged.
Use of nasal speculum to visualize nasal cavity and septum. Exudate or disorders of the septum should be noted.
). A fiberoptic examination can be carried out along with percussion and palpation over the maxillary and frontal sinuses to denote tenderness.
Use of tongue blade to suppress one side of tongue base to visualize tonsil area and posterior pharyngeal area.
Palpation of tonsillar fossa and base of tongue area with gloved hand. Unusual hardness, enlargement, or tenderness is noted.
Retraction of cheek to show opening of Stensen's Duct opposite the second upper molar.
Bimanual palpation of submaxillary gland and contents of submaxillary triangle.
Palpation of parotid gland for enlargement, induration, tenderness or stones.
). The patient may need to have a CT scan of the salivary glands, which can be extremely helpful in evaluating occult lesions. Examination of this area should include inspection of the palate, tonsillar fossae, gums, tongue, cheeks, teeth, and the openings of the submaxillary and parotid ducts (Chapters 129–131) (Figures 119.5 and 119.6). Careful bimanual palpation of the submaxillary gland (Figure 119.7) with palpation and massage of the parotids (Figure 119.8) with observation for secretion from the ducts should be carried out.
Palpation of jaw joint for tenderness or crepitance is helpful in the diagnosis of temporomandibular joint disorder.
). The patient should be asked to bite down firmly on a wooden tongue blade to see if this will elicit pain in the joint. Tapping on the teeth with a metal probe may help identify isolated dental disease that is referred to the jaw joint area.
Palpation of thyroid gland from the front. Right hand displaces the gland to left of patient while left hand, index finger, and thumb palpate gland under steno-cleido-mastoid muscle.
), larynx, and hyoid bone should be done (Chapter 132). Mirror or fiberoptic examinations are vital in order to document the motion of the vocal cords and lesions of the epiglottis and larynx.Careful inspection of the face as a patient talks will reveal many factors. The examiner should look carefully for signs of trauma, previous facial surgery, eye swelling, or "bags under the eye," which might indicate fluid or allergic disorders. The quality of the skin can be quickly noted. The patient should be evaluated in the presence of good lighting (preferably sunlight), and it is often helpful if cosmetic surgery is to be considered to have frontal and profile photographs taken. Examination of the face involves inspection for blepharochalasia (eyelid sagging), excess wrinkling, or redundancy of skin in various areas of the chin, neck, upper neck, and face. Regional inspection of the face should be made to document skin lesions such as keratoses, moles, or scars. Facial asymmetry, nasal distortions, prominent ears, malocclusion (overbite or underbite), or excessive hair should be documented. Enlargement in the sides of the face, which indicates masseter hypertrophy or abnormal facial movements such as tics, should be documented. The patient should have the face palpated for tenderness or protrusions, and for any associated lymph node enlargement in the submandibular or preauricular areas. The patient should be asked to perform basic facial movements, such as smiling, pursing the lips, and closing the eyes tightly, to document any asymmetry of motion or previous facial paralysis.
Many specific and general questions are needed in order accurately to evaluate a person with a communication disorder (Chapter 126). One of the first observations to be made is the loudness of the patient's voice as he or she speaks, since many patients with conductive loss talk very softly, whereas patients with sensorineural hearing impairment talk loudly. The obvious response of the patient to the examiner's normal voice will provide clues as to the severity of hearing impairment.
Examination of external auditory meatus. Pinna should be pulled upward and backward.
). Standard hydrogen peroxide or aqueous zephiran is helpful to dissolve wax. A standard 256 Hz tuning fork is necessary for adequate Weber and Rinne testing. The use of an electric audiometer, an impedance bridge, routine mastoid films, cultures of the ear canal, or CT scans of the temporal bone are often needed for complete evaluation.
Examination of external ear canal and eardrums with otoscope. Pinna should be pulled upward and backward. Otoscope should be angled in several directions.
Weber test for lateralization of sound. Fork should be placed in midline of head after being set in motion. Patient should be asked if sound is heard best in right or left ear. Normally sound will not lateralize either way.
). The Weber and Rinne test should be performed in a quiet area and recorded (Figures 119.13–119.15). Air conduction with a tuning fork should be compared between ears to note any difference. The patient's response to normal conversation when facing the examiner and with the face turned away should be noted. All secretions from the ear should be cultured. The eyes should be checked for nystagmus in all gazes and at the time of pressure with the pneumatic otoscope to document the possibility of nystagmus created by ear pressure movement. Romberg and tandem gait tests should be performed on patients who have any complaints of vertigo (Chapter 127). It is also helpful to carry out standard Hallpike maneuvers to determine positional nystagmus.
