I.  Overview of focused-assessment of the Head, Eyes, Ears, Nose,  and Throat (HEENT)

The assessment of the head and neck and structures contained in this area such as the eyes, ears, nose and throat is  an important element of health assessment of an individual. The examination  of these structures will also make up assessment steps of different body systems assessment such as neurologic, respiratory, cardiovascular and musculoskeletal and integumentary, which will be discussed in further details in subsequent sections. In many instances the assessment of these structures are incorporated in various focused assessments of the different body systems. The assessment findings of the anatomy and function of the HEENT reflects the condition of the different body systems.

Objectives:

This chapter will guide the student to:

1.   Obtain HEENT health history from the patient.
2.   Perform physical assessment of the HEENT and neck using correct techniques.
3.   Identify any hearing loss through the use of conversation or if needed the whisper or finger rubbing test.
4.   Document findings of the HEENT and neck exam.

II. Anatomy and Physiology

Watch and learn from the following videos:

1. Landmarks of the Head and Neck

2. Muscles of the Head and Neck

3. Structures and functions of the eyes

4. Anatomy of the Ear

5. Anatomy of the Nose

III. Related Medical Terminology

• Occipital – back of the head
• Photophobia – intolerant of light
• Phonophobia – intolerant of sounds
• Diplopia – double vision
• Epistaxis– nosebleed
• Rhinorrhea – runny nose or nasal
discharge
• Otorrhea – discharge from the ear
• Tinnitus – ringing noise in the ear
• NCAT = normocephalic, atraumatic
• PERRL = Pupils Equal Round and
Reactive to Light
• Erythema = redness
• Exudate (tonsilar) = most commonly
white spots on the tonsils, but can be
any fluid or cellular matter deposited
on any tissue
• Purulent = consisting of pus
• Injected = blood vessel congestion,

•  Wash your hands (foam in)
•  Introduce yourself to the patient
•  Determine how the patient prefers to be addressed
•  Explain your role in the health care team
• Negotiate an agenda for the encounter

HEENT Exam

 Head

• Inspect hair for quantity, distribution, texture, pattern of loss
•  Inspect scalp and face for asymmetry, involuntary movements, edema or masses

Eyes

•  Inspect general appearance of eyes including lids, lashes, conjunctiva, and sclera
•  Test extraocular movements (CN III, IV, VI) in an H pattern while stabilizing head
•  Test for convergence by moving finger toward bridge of nose
•  Test pupillary near reaction for accommodation
•  Evaluate upper and lower visual fields by confrontation (CN II) in each eye
•  Assess visual acuity in each eye individually using an eye chart (20 feet away) or eye card (14 inches away) with glasses if patient wears them
•  Determine pupil size bilaterally and compare for equality
•  Test pupillary reaction to light (CN II, III) directly and consensually
•  Perform a fundoscopic exam to evaluate blood vessels for narrowing, AV nicking, hemorrhages, or exudates
•  Evaluate the optic discs

 Ears

•  Inspect external appearance of ears including auricle, tragus, helix, and lobule
•  Palpate the tragus and auricles bilaterally
•  Test gross hearing using the finger rub (CN VIII)
•  Perform an otoscopic exam

 If gross hearing test is abnormal, then perform the following optional tests:

• Perform Weber test (CN VIII) by placing a vibrating tuning fork in the midline of the forehead and assess for laterality
•  Perform Rinne test (CN VIII) by placing the base of a vibrating tuning fork on the mastoid and then next to the ear canal; assess whether air conduction is greater than bone conduction

 Nose and Paranasal Sinuses

•  Inspect the nose for asymmetry or deformity
•  Inspect nasal mucosa and septum with otoscope to assess for deviation, inflammation, or perforation
•  Palpate the frontal and maxillary sinuses to assess for tenderness

If the patient reports difficulty smelling, perform the following test:

•  Test olfactory nerve (CN I): While the patient closes one nostril with a finger, have them identify a smell (ex. coffee beans, cinnamon). Repeat for other side.

 Mouth

•  Inspect oral mucosa, gums, and dentition using a penlight or otoscope
• Inspect undersurface and sides of tongue and floor of mouth
•  Inspect posterior pharynx, tonsils, and uvula (use tongue depressor if needed)

 Neck

• Inspect neck for asymmetry, atrophy, swelling, masses or scars
•  Palpate preauricular, posterior auricular, and occipital lymph nodes
•  Palpate tonsillar, submandibular, and submental lymph nodes
•  Palpate superficial cervical, posterior cervical, deep cervical lymph nodes
•  Palpate supraclavicular lymph nodes
•  Examine thyroid gland using a posterior approach while patient swallows

Closure

• Summarize information gathered in physical exam
• Inquire if patient has questions or concerns
• State appreciation to patient
•  Shake hands (if appropriate)
•  Wash your hands (foam out)

Watch and learn:

V. Related Laboratory and Diagnostic Findings

• Eye examinations
• Hearing Tests
• Nasal Endoscopy

VI. Documentation

The following is a sample documentation of normal findings of HEENT.

HEAD AND NECK
Head symmetrically round, hard, and smooth without lesions or bumps.  Face oval, smooth, and symmetrical.  Temporal artery elastic and nontender.  Temporomandibular joint palpated with full range of motion without tenderness.  Neck symmetric with centered head position and no bulging masses.  C7 is visible and palpable with neck flexion.  Has smooth, controlled, full range of motion of neck.  Thyroid gland nonvisible but palpable when swallowing.  Trachea in midline.  Lymph nodes nonpalpable.

EYE AND EAR
Acuity by Snellen chart O.D. 20/20, O.S. 20/20.  Visual fields full by confrontation.  Extraocular movements smooth and symmetric with no nystagmus.  Evelids in normal position with no abnormal widening or ptosis.  No redness, discharge, or crusting noted on lid margins.  Conjunctiva and sclera appear moist and smooth.  Sclera white with no lesions or redness.  No swelling or redness over lacrimal gland.  Cornea is transparent, smooth, and moist with no opacities, lens is free of opacities.  Irises are round, flat, and evenly colored.  Pupils are equal in size and reactive to light and accommodation.  Pupils converge evenly.
Ears are equal in size bilaterally.  Auricles are aligned with the corner of each eye.  Skin smooth, no lumps, lesions, nodules.  No discharge.  Nontender on palpation.  Small amount of moist yellow cerumen in external canal.  Whisper test : patient repeats 2 syllable word.

MOUTH, THROAT, NOSE, AND SINUS
Lips pink, smooth, and moist without lesions.  Buccal mucosa pink, moist, and without exudates.  Stensen/s ducts visible with no redness or swelling.  32 white to yellowish teeth present.  Gums pink without redness or swelling.  Protrudes geographic tongue in midline with no tremors.  Equal bilateral strength in tongue.  Ventral surface of tongue smooth and shiny pink with small visible veins present.  Frenulum in midline.  Soft palate smooth and pink.  Tonsillar pillars pink and symmetric.
Nose somewhat large but smooth and symmetric.  Able to sniff through each nostril. Nasal septum slightly deviated to the left, but does not obstruct airflow.  Inferior and middle turbinates dark pink, moist, and free of lesions.  No purulent drainage noted.  Frontal and maxillary sinuses  are nontender to palpation and percussion.

VI. Learning Exercises

Practice assessment of the HEENT. Document in electronic medical record or hand write assessment findings in the patient’s medical record.

VII. Citation and Attribution:

Daniel M, Rougas S, Warrier S, Tabaddor R, Bray K, Taylor J. Teaching physical exam skills to novices: developing all the  tools in the clinician toolbox. MedEdPORTAL. 2015;11:10057. https://doi.org/10.15766/mep_2374-8265.10057

Swift, Heather ( 2013). Charting example for physical assessment.  https://othersideofthestethoscope.wordpress.com/2013/10/24/charting-examples-for-physical-assessment/

US National Library of Medicine.   https://medlineplus.gov/