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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2853_Библиотеки_им_академика_М_И_Перельмана
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176 CHAPTER 7: The Head and Neck
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FIG. 7-18 Testing for Strabismus.
deviation or phoria is present. The cover-uncover test has shown that the brain
can fuse images by aligning the visual axes, but alternating cover breaks that
fusion. A phoria is also demonstrated by xing focus on an object with both
eyes then covering one eye for a few seconds. If the covered eye moves to
reestablish xation when uncovered, the eye has heterophoria.
Naming the deviation. If the eye swings inward to pick up xation, it was
initially deviated outward (exotropia or exophoria). If the eye swings outward,
it was initially deviated inward (esotropia, esophoria). To determine if the heterotropia is comitant or incomitant, have the patient follow a target in the six
cardinal directions of gaze. If the eyes move equally without restriction, the
deviation is comitant. If one eye over-shoots and the other fails to move the
entire distance in one or more directions, the deviation is incomitant, either a
paralytic or restrictive misalignment. A paralytic misalignment is pathological
and could indicate ischemia (stroke) or compression (tumor); restrictive mis-
alignments are caused by scarring or brosis, as in thyroid eye disease.
Eyelids. Look for swelling of the lids, and above, below, and near the canthi.
Note inversion or eversion of the lid margins. Examine the margins for scaling, normal secretions, exudate, papules, or pustules. Look for lashes turned
inward (trichiasis). If pressing the lacrimal sac expresses uid through the
punctum, the tear duct is obstructed.
Bulbar conjunctiva and sclera. Gently retract the lids with the thumb and
forenger. Note the color of the sclera, any pigment deposits, vascular
engorgement, or vascular pterygium. A pinguecula is avascular.
Palpebral conjunctiva. To evert the lower lid (Fig. 7-19A) place the thumb
tip on the loose skin beneath the lid margin and slide the skin down, pressing it gently into the orbit. With the patient looking up, look for congestion,
discharge, and/or other lesions. If indicated, evert the upper lid (Fig. 7-19B).
Have the patient look downward with both eyes open to prevent the elevation accompanying lid closure. Pinch the upper lid lashes and gently pull the
lid downward and away from the globe. Press the cotton tip of an applicator
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FIG. 7-19 Examination of the Eyelids. A. Eversion of the lower lid. B. Eversion of the upper lid: Tell the
patient to look downward and proceed with four steps: (1) with the right thumb and forefinger, grasp a few cilia of the upper
lid and pull the lid away from the globe; (2) lay an applicator along the crease made by the superior edge of the tarsal plate
and the soft adjacent tissue; (3) quickly fold the lid over the applicator so the tarsal plate turns over and its upper edge faces
downward; and (4) replace the right thumb and finger by the corresponding left ones to hold the lid. C. Testing pupillary
reaction to light.
against the upper lid just above the tarsal plate. Using this as a fulcrum, pull
the eyelid quickly upward everting the tarsal plate. Stabilize the everted lid
with your ngers. To return the lid to its normal position have the patient
glance upward.
Cornea. To search for scars, abrasions, or ulcers, shine a light obliquely on
the cornea. The corneal light reex should be smooth and regular as the light
is played over the surface. Abrasions are readily demonstrated by uorescein
staining. Place the tip of a moistened uorescein strip in the inferior fornix.
After removing it, have the patient blink. Corneal abrasions are green under
blue light. The cornea may also be examined with a lens.
Iris, pupils, and lens. Observe the clarity of the iris, noting whether it is distinct or muddy. Look for new vessels and deposits. Note pupil size, shape,
and equality. Shining light obliquely through the lens reveals deposits on the
lens surface and opacities in the matrix such as cataracts.
Testing the pupil's reaction to light. Have the patient x focus on an object
>3 m (>10 ft) away. Shine light into the right pupil from the side (Fig. 7-19C)
while observing the direct pupillary reaction. Repeat on the left eye. Next, while
continuing to observe the left pupil, swing the light back to the right eye.
Normally, as the light swings toward the right eye from the left, there is minimal dilatation followed by constriction of the left pupil, the normal consensual
178 CHAPTER 7: The Head and Neck
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reaction. Repeat, observing the right pupil as the light moves to the left eye
from the right eye. This is the swinging light test for a relative afferent pupillary
defect (RAPD, Chapter 14, page 665).
Testing pupillary reaction to near point. Have the patient x on his/her own
nger as it is gradually brought closer to his/her nose; the pupil should constrict.
Schirmer test of tears. A thin strip of lter paper is folded over the lower eyelid without anesthesia. Wetting extending <10 mm after 5 minutes indicates
decreased tear formation, keratoconjunctivitis sicca (Fig. 7-34D, page 201).
Ophthalmoscopic exam. Ophthalmoscopic examination requires considerable practice. Examine the right eye observing with your right eye
while using your right hand to manipulate the ophthalmoscope. Examine
the left eye using your left eye with the ophthalmoscope in your left
hand (Fig. 7-20). Undilated examination of the right eye is described.
Grasp the instrument with your right hand, your forefinger on the disk
of lenses. Rest your left hand on the patient’s forehead so that your
thumb can pull the upper lid slightly upward uncovering the pupil and
preventing excessive blinking. Have the patient fix vision straight ahead
on a distant object.
Media. Place the +8 or +10 diopter lens in the sight hole. Bring it close to your
eye or glasses and move forward to ~30 cm (12 inch) in front of the patient’s
eye. Shine the light into the pupil to see the red retinal reex. A dull red or black
reex is produced by diffuse dense opacities. Look for black spots showing
against the red. These shadows of lens or vitreous opacities are made by
light reecting from the retina. Move forward or backward until the spots
are clearly focused. While watching the opacities, ask the patient to elevate
the eyes slightly; if the spots move upward, they are on the cornea or anterior
lens; little movement occurs when located near the lenticular center; downward movement indicates location in the posterior lens or vitreous. Vitreous
opacities are more distinct when viewed obliquely with the white optic disk
as background.
FIG. 7-20 Ophthalmoscopic Examination.
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FIG. 7-21 Normal Fundus. Normal left retinal vessels, macula, periphery and disc. (Image used with permission from
Brice Critser, CRA.)
Fundus (Fig. 7-21). Hold the instrument ~5 cm (2 inch) from the patient’s
eye with your forehead near or touching the hand on the patient’s forehead.
Adjust the lenses to nd the optimal focus for viewing the retina, the setting
varies with the refractive error and degree of accommodation in both patient
and examiner. Absent both factors, the best view should be at zero. Minus
lenses correct for involuntary accommodation. After cataract extraction without intraocular lens placement, about +10 is needed for correction. High
astigmatism cannot be corrected with the spherical ophthalmoscope lenses,
so examine through the patient’s glasses. When the correct setting is found,
examine the following (Fig. 7-21 and Fig. 7-39A, page 206).
Optic disk. The optic disc lies 10 degrees nasal and slightly inferior to the
visual axis. Therefore, angle the ophthalmoscope 10 degrees nasally from the
line of sight to locate the optic disc. Note the disk’s shape and color. Normally,
it’s round or oval vertically. Most of the disk is red-orange, the color coming
from capillaries around nerve bers. The physiologic cup is a pale area at the
center of the disk devoid of nerve bers and forming a depression whose base
is the avascular lamina cribrosa. The size and shape of the cup vary greatly in
normal eyes. Estimate the cup-to-disk ratio. If the cup is not circular, use the
vertical ratio. Vessels enter and exit at the pale and white vessel funnel, which
also lacks nerve bers. The disk borders may merge gradually into the surrounding retina, or they may be sharply demarcated by a white scleral ring.
On the temporal side outside the ring, a crescent of pigment may be present.
Retinal vessels. Arteries are bright red with a light reex, the central stripe.
Note the width of the reex stripe. Normally, veins are wider than the arteries
in a ratio of ~4:3 and they are darker red and lack a stripe. The vessel branching pattern shows great individual variation. Emerging from the disk, the
afferent vessels are true arteries; branches beyond the second bifurcation, ~1
disk diameter from the disk margin, are arterioles. Look for sheathing of the
arteries. Observe the veins carefully at the arteriovenous crossings for nicking, deviation, humping, tapering, sausaging, or banking. Retinal veins are
normally pulsatile; retinal arteries are not.
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Retina. Retinal pigmentation varies with the patient’s complexion and race.
The retina is thinner and therefore more pale in the nasal periphery. Note
areas of white or pigment from scarring. Look for hemorrhages and exudates.
Express the size of abnormalities in disk diameters. Measure depression or
elevation by the diopters of correction required to focus on an arterial reex
in the area.
Macula. Examine the macula last. It is slightly below the horizontal plane of
the disk and 2–3 disk diameters temporal of its margin. Observation of the
macula is usually eeting because the light causes discomfort. The fovea in
the center of the macula is a small darker red area set apart from visible vessels. In its center is a small even darker spot, the foveola, giving off a speck of
reected light.
Testing visual acuity. Gross tests of visual acuity are made without special
equipment. Test one eye at a time. Have the patient read a newspaper or magazine, testing rst with the ne print and following with larger print if needed.
If the patient fails large letters, ask him to count several ngers held 1 m
(3 ft) away. If he cannot count them, ask if he can see hand movements. Failing
this, ash light into the eye, asking for an indication of when it appears. Ask
whether he can tell the direction of the light source. When gross acuity is fair,
standard Snellen chart testing when done with adequate illumination at the
appropriate distance provides greater accuracy. Determine the smallest line
of letters the patient can read without error with each eye, and then with both
eyes together. Acuity is expressed as the ratio of the distance at which the
patient read the line to the distance at which the line is read by normal eyes.
The distance is expressed in feet or meters; 20/20 ft and 6/6 m are normal,
respectively. If the patient could only read the line for 40 ft, his/her acuity is
expressed as 20/40. Record whether glasses or contact lens were used. If the
visual acuity is abnormal, the potential acuity from improving optical correction is estimated by the pinhole test. A 1-mm hole, or series of holes, is made
in a card. The patient is asked to read a Snellen chart through the pinhole(s)
providing a close approximation to best-corrected visual acuity.
Testing color vision. Perceived colors are mixture of red, blue, and green. Ask
the patient to identify the colors of objects immediately available. Use a book
of Ishihara plates for greater accuracy.
Slit-lamp microscopy. Slit-lamp exam is reserved for vision professionals and
those with extensive experience. A narrow slit of powerful light is focused on
the layers of the cornea, anterior chamber, lens, and anterior third of the vitreous chamber looking for opacities and foci of inammation.
Examining the Nose and Sinuses: Routinely inspect the nose’s prole, con-
tour, and symmetry. Test patency of each naris by closing the other while the
patient inhales with the mouth closed. Transilluminate the nasal septum by
pushing the nasal tip upward and illuminating one naris (Fig. 7-22A) while
viewing the transilluminated septum through the opposite nares for deviations, perforations, and masses. Palpate the cheeks and supraorbital ridges
and over the maxillary and frontal sinuses for tenderness.
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FIG. 7-22 Examination of the Nasal Septum and Nares. A. Transillumination of the nasal septum.
B. Speculum examination of the nose.
Examining with a nasal speculum. Examine the anterior nasal chambers with
a nasal speculum and a head mirror or head lamp. Holding the speculum in
the left hand (Fig. 7-22B) leaves the right hand free to position the head and/
or hold instruments. Insert the closed blades ~1 cm into the vestibule before
opening the blades in the plane of the septum. Anchor the ala nasi against
the superior blade with the left forenger to avoid pressure on the septum.
Reposition the speculum and head to see each structure. Examine the vestibule
for folliculitis and ssures. Note the color of the mucosa and any swelling.
Inspect the nasal septum for deviation, ulcer, or hemorrhage. Examine the
inferior turbinate on the lateral wall for swelling, increased redness, pallor, or
blueness. Identify the middle turbinate and inspect the middle meatus for purulent discharge from frontal, maxillary, and anterior ethmoid sinuses.
Nasopharynx. A head mirror or headlamp is required for illumination.
Warm a No. 0 (small) postnasal mirror in warm water to avoid condensation; check its temperature on your wrist. Depress the tongue, as described
for the oropharyngeal examination, inserting it from the corner of the mouth
(Fig. 7-23A). Hold the mirror like a pencil, steadying your hand against the
patient’s cheek. Insert the mirror from the side opposite the tongue blade,
keeping the mirror upright to avoid touching the tongue, palate, and uvula.
Position it behind the uvula near the posterior pharyngeal wall. Turn the mirror upward to view the choana (Figs. 7-23B and C) locating, in the midline,
the vomer, the posterior end of the nasal septum. Identify the middle meatus.
Pus draining posteriorly from the meatus comes only from the maxillary
sinus. The inferior meatus is not well visualized posteriorly. The pale or yellow
~5 mm diameter orices of the auditory (Eustachian) tubes are behind and lateral to the middle meatus. The tubes are closed except during swallowing or
yawning. Look for the pharyngeal tonsil (adenoids) hanging from the roof into
the fossa. Examine the nasopharynx for inammation, exudate, polyps, and
neoplasms. If available, a beroptic instrument simplies the exam.
Sinus Transillumination. Use a cool light in a fully darkened room. For the
maxillary sinuses, press a cool light against each maxilla while observing the
182 CHAPTER 7: The Head and Neck
B. View of choana in the
C. Sagittal view
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Middle concha
(turbinate)
Orifice of
auditory tube
(eustachian)
postnasal mirror
A. Examination with the postnasal mirror
Examination of the Nasopharynx. A. Examination with the postnasal mirror. In th e drawing, all
FIG. 7-23
deep spaces are heavily stippled. B. View of the choana in the postnasal mirror. C. Sagittal view.
hard palate through the mouth for transmitted light. For the frontal sinuses,
place the light under the nasal half of the supraorbital ridge while shielding
the orbit to the eyebrows. Look for bright areas in the forehead. Asymmetry
of transillumination is most signicant.
Examining the Lips, Mouth, Teeth, Tongue, and Pharynx: Inspect using a
tongue blade and light. Using a headlamp or mirror frees one hand for instruments. Completely inspect the oral cavity before beginning palpation.
Lips. Look for congenital and acquired defects. Note the lip color and look
for angular stomatitis, rhagades, ulcers, granulomas, and neoplasms. Having
the patient attempt to whistle reveals weak face muscles that are innervated
by the facial nerve (CN-VII). Inspect the inner surface of the lips by retracting
them with a tongue blade while the teeth are approximated.
Teeth. Note the absence of teeth and the presence of caries, discoloration,
llings, and bridges. Note abnormal shapes, such as notching. Tap each tooth
for tenderness.
Gums. Have the patient remove any dental appliances. Look for retraction
of the gingival margins, pus in the margins, gum inammation, spongy or
bleeding gums, lead or bismuth lines, or localized gingival swelling.
Physical Examination of the Head and Neck 183
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FIG. 7-24 Palpation of the Roof of the Tongue.
Breath. Smell the breath for acetone, ammonia, or fetor.
Tongue. Have the patient protrude the tongue for inspection. Assess its size
noting deviation from the midline or restricted protrusion. Examine the dorsal surface coat for color, thickness, and adhesiveness. Have the patient raise
the tongue tip to the roof of the mouth to inspect the undersurface, including
frenulum and carunculae sublingualis. To relax the muscles for palpation, have
the tongue inside the teeth for palpation. Wear gloves and with the mouth
widely open, push a fold of cheek between the teeth to lessen the chance of
being bitten. Insert a forenger to the back of the mouth and palpate the roof
of the tongue, valleculae, and tonsillar fossae (Fig. 7-24) for tenderness and
masses. Palpate the sublingual salivary glands and submandibular ducts for
calculi. Spraying the throat with a topical anesthetic reduces an overactive
gag but is usually unnecessary.
Examining a lingual ulcer. Always wear gloves. Using a cotton sponge, gently dry the ulcer and then inspect it carefully. Palpate the surrounding and
underlying tissue. Pain from lingual lesions may be referred to the ear.
Buccal mucosa. Retract the cheek with a tongue blade looking for melanin
deposits, vesicles, petechiae, Candida, Koplik spots, ulcers, and neoplasms.
Examine the orice of the parotid duct opposite the upper second molar.
Oropharynx. Hold a tongue blade with the thumb underneath and the index
nger and long nger on top at the midpoint. Have the patient breathe
steadily through the nose keeping the mouth open. Relax the tongue with
the tip behind the lower incisors. Using the blade’s tip, press the tongue’s
midpoint downward and forward by pushing down with the two ngers
while the thumb pushes upward on the end (Fig. 7-25A). Pressing farther
back causes gagging, while pressing anteriorly leads to posterior bulging.
Steady the light in the other hand with the ring and little ngers on the
patient’s cheek. An optimal view may require several blade placements
transversely at the midpoint. Test for vagal nerve (CN-X) paralysis by noting whether the uvula is drawn upward in the midline when the patient
says “e-e-e.”
Tonsils. Use a tongue blade in each hand. Depress the tongue with one while
retracting the anterior faucial pillar laterally with the other, disclosing the
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FIG. 7-25 Examination of the Oral Cavity. A. Use of the tongue blade. B. Principal anatomic features
seen in the oral cavity.
FIG. 7-26 Anatomy of the TMJ. Note the nearness of the joint to the external acoustic meatus, so the joint may be
palpated by a finger in the meatus (Fig. 7-6 6).
anterior tonsillar surface. Normally, it’s the same color as the surrounding
mucosa. Look for hyperplasia, ulcers, membrane, masses, and small, submerged tonsils.
Examining the Temporomandibular Joint: Palpate over the temporoman-
dibular joint (TMJ), anterior to the tragus, while the patient opens and closes
the mouth, feeling for clicking or crepitus (Fig. 7-26). Corresponding noises
are heard by placing the stethoscope bell over the joint during movement.
Search for tenderness by placing the index nger tips in each external acoustic meatus and press forward while the mouth is opened and closed.
Examining the Larynx
Mirror laryngoscopy. This technique is being largely replaced by use of exible
beroptic instruments. Use a head mirror or head lamp leaving both hands
free. To use a mirror, seat the patient with a bright light source immediately
behind and to one side of the head. Reect this light into the oropharynx
with the head mirror; practice is required. The patient sits erect with the chin
somewhat forward. The examiner sits in front of the patient with the knees
outside the patient’s knees. Explain each step of the procedure before beginning. Have the patient concentrate on breathing softly and regularly through
the mouth (Fig. 7-9A, page 169). Have the tongue protrude maximally over
the lower teeth. After rapping a piece of gauze over the tongue, grasp the
wrapped portion between thumb and middle nger of the left hand while
Physical Examination of the Head and Neck 185
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bracing with the forenger against the upper teeth. Pull the tongue gently
to the side. Hold a No. 5 (large) laryngeal mirror like a pencil at the handle’s
midpoint. To avoid condensation, warm the mirror in warm water checking
its temperature on your wrist. Brace your fourth and fth ngers against the
patient’s cheek. Insert the mirror from the side, with the face downward and
parallel to the tongue surface. Move it posteriorly until its back rests against
the anterior surface of the uvula. Press the uvula and soft palate steadily
upward. To prevent gagging, avoid touching the back of the tongue. Have
the patient breathe steadily while you inspect the larynx. While still viewing
the vocal cords, ask the patient to say “e-e-e” or “he-e-e” in a high-pitched
voice. Sing along with him in the desired pitch and for the proper duration.
When viewing in the mirror, remember that upward is anterior, downward
is posterior. Examine the vallate papillae, lingual tonsils, valleculae, and epiglottis
(Fig. 7-9B, page 169). Next, look at the false cords, true vocal cords, arytenoids,
and piriform sinuses. Finally, observe the true vocal cords during quiet respira-
tion when the rima is tent-shaped. During phonation, watch the cords meet
in the midline.
Examining the Salivary Glands
Parotid glands. When fullness is present anterior to the tragus, ascertain
whether it is continuous with an inferior mass, as in parotid swelling, or discontinuous, as in swelling of a preauricular lymph node. Swelling from the
parotid gland is seen in front of the tragus and earlobe and behind the lower
ear, pushing the pinna outward. Have the patient clench his teeth tensing the
masseter muscles. Palpate against the hard muscle to determine the mass’s
extent, consistency, and tenderness. Feel for swelling behind the mandibular
ramus, which is always present in parotid enlargement. Palpate for calculus
in the parotid duct. The normal duct is thick enough to be felt when rolled
against the tensed masseter. Inspect the parotid duct orice. While watching
the orice, press the cheek looking for discharge from the duct. With a gloved
nger, palpate the orice and posteriorly for calculus or other mass.
Submandibular glands. Do bimanual palpation with a gloved nger in the
oor of the mouth and the opposite hand under the jaw. The gland is felt as a
nely lobulated swelling under the mandible slightly anterior to the angle of
the jaw. To test for secretion, place cotton gauze under the tongue, have the
patient sip lemon juice, and then remove the gauze watching for saliva owing from each orice.
Examining the Neck
Cervical muscles and bones. In trauma cases or if cervical fracture is
suspected, immobilize the patient and obtain X-rays before trying to elicit
physical signs. Have the patient’s neck and shoulders uncovered. Face the
patient looking for swelling and noting any asymmetry of shoulder height
and clavicles, or xed neck posture. Check range of motion on neck exion,
extension, lateral bending, and rotation. Palpate the cervical vertebrae and
muscles for tenderness, tightness, and masses.
Thyroid gland. The normal adult thyroid is often not palpable. In a thin neck,
the normal isthmus is felt as a tissue band just obliterating the surface of the
tracheal rings. A goiter is any enlarged thyroid gland.
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