1. ASSESSING THE HEAD,
FACE, AND NECK
Dr/Magda Bayoumi

2.  The head, face, and neck form a large portion of what
is often referred to as the head, eyes, ears, nose, and
throat (HEENT) system. This is actually a complex
set of varied organs, combined during assessment
because of their proximity to one another and the
integration among the components of the system.

11. INTERACTION WITH OTHER SYSTEMS
ENDOCRINE
Thyroid and parathyroid glands located in neck.
RESPIRATORY
Respiratory tract begins at nasal and oral cavities.
Injuries to head and face can affect breathing.
Respiratory infections often begin in upper airways of
nose and throat.
INTEGUMENTARY
Skin-color changes on face (e.g., cyanosis, pallor,
jaundice) may indicate systemic problems.
DIGESTIVE
Mouth is beginning of digestive tract.

12. CARDIOVASCULAR
Temporal and carotid arteries located in head and neck. Neck
and jaw pain may indicate cardiovascular disease.
MUSCULAR
Facial muscles needed for expression, communication and
nutrition.
URINARY
Changes in face (e.g., edema or uremic frost) may reflect renal
problems.
LYMPHATIC
Cervical lymph nodes located in neck. Tonsils located in pharynx.
Mast cells located in pharynx
SKELETAL
Skull protects brain.
REPRODUCTIVE
Pregnancy can cause changes in facial color (chloasma). Lips
and mouth are erogenous areas.


13.  Two landmarks on the face that are useful in determining
symmetry of facial features are the palpebral fissures
and the nasolabial folds.
 The palpebral fissure is the distance between the upper
and the lower eyelid.
 The nasolabial fold is the distance from the corner of the
nose to the edge of the lip.
 This is the facial crease that is often seen when someone
smiles.
 The anterior and posterior triangles are important
landmarks of the neck.
 The sternocleidomastoid and trapezius muscles form
the triangles.
 Both triangles are helpful in locating the underlying
structures of the neck.

14. ANATOMICAL LANDMARKS

15.  The tools that will be necessary to examine the
head, face, nose, mouth, throat, and neck are a
penlight or otoscope for focused light, tongue
blades, gauze, stethoscope, transilluminator,
cup of water, and gloves.
If you are using an otoscope as a light source, you will
want a wide-tipped speculum. A nasal speculum is
another useful piece of equipment. Lighting is very
important, and some examiners prefer also using a
gooseneck lamp or headlamp when examining the
mouth and throat.

16. Assessing the Head and Face
Head Size:
■ Inspect head size and shape and symmetry of facial
features.
■ Variation is wide, between and within gender and
racial/ethnic group.
Inspecting head size and shape and symmetry of
facial features

17. A B N O R M A L F I N D I N G S / R AT I
ONALE
■Abnormal increase in head size in young child:
May indicate hydrocephalus.
■ Inconsistently large head size in adolescent or
adult: May indicate acromegaly.

20. 2-Head Shape:
 Variation is wide, although shape should be
symmetrical and contour rounded.
3-Facial Appearance:
 Facial appearance varies by gender, age, and
racial/ethnic group. However, there should be
symmetry of features and movement.

21. A B N O R M A L F I N D I N G S / R AT I O N A L E
 ■Facial appearance inconsistent with gender, age, or
racial/ethnic group: May indicate an inherited or chronic
disorder with typical facies, such as Graves’
disease, hypothyroidism with myxedema, Cushing’s
syndrome, or acromegaly.
 ■ Asymmetry of features: Previous trauma, surgical
alterations, congenital deformity, paralysis, or edema.
Asymmetry is also seen with Bell’s palsy and stroke.
 Asymmetry of movement: Suggests neuromuscular
disorder or paralysis. Tics, or spastic muscular
contractions, usually occur in the head and face.

22. GRAVES’ DISEASE

25.  Two good places to inspect for symmetry of facial
features are the palpebral fissures and the nasolabial
folds.

26. PALPATION OF THE HEAD AND FACE
Head Contour/Facial Structures
■ Use light palpation to note head size, shape,
symmetry, masses or areas of tenderness.
■ Use light palpation to palpate the scalp for mobility
and tenderness.
■ No tenderness or lesions.
■ Relatively smooth with no unexpected contours or
bulges.

28. A B N O R M A L F I N D I N G S / R AT I O N A L E
■ Contour abnormalities, including bulges or projections:
Previous trauma, surgery, or congenital deformity.
■ Tenderness: Trauma, TMJ syndrome, temporal arteritis, or
inflammatory process.

29. TMJ (Temporo-mandibular Joint)
Palpate the TMJ by placing fingers over the TMJ and
palpating the joint as the patient opens and closes his or
her mouth.
■ Smooth, symmetrical motion, with no pain, crepitus, or
clicking.
A B N O R M A L F I N D I N G S / R AT I O N A L E
■ Irregular or uneven movement, pain with motion, or
crepitus/popping: TMJ syndrome.

30. ASSESSING THE SINUSES
Assessment of the sinuses includes inspection (with
transillumination), palpation,and percussion.Only the
frontal and maxillary sinuses are readily accessible for
assessment.
Remember, the frontal sinuses are located above the
eyebrows and the maxillary sinuses are located
below the eyes.

31. INSPECTION OF THE SINUSES
Frontal and Maxillary Sinuses
Inspect frontal sinuses above the eyes and maxillary
sinuses below the eyes.
No periorbital edema or discoloration.
A B N O R M A L F I N D I N G S / R AT I O N A L E
■ Periorbital edema and dark undereye circles: Sinusitis.

32. Frontal and Maxillary Sinuses by Transillumination
■ Transilluminate frontal sinuses by shining light upward under
eyebrow.
■ Transilluminate maxillary sinuses by shining light below eyes
while looking for a red glow on the roof (palate) of the mouth.
Frontal sinus: Normally, red glow noted above eyebrow.
Maxillary sinus: Normally, red glow noted on roof of mouth.
■ Expected variations include absence of transillumination
because the ability to transilluminate is dependent on the
thickness of the bones overlying the structure examined.


33. A B N O R M A L F I N D I N G S / R AT I O N A L E
Absence of transillumination over one sinus when opposite
structure transilluminates:
 Mucosal thickening or sinus fullness with sinusitis.
■ Absence of transillumination must be considered with other
findings.

36. PALPATION OF THE SINUSES:
Frontal and Maxillary Sinuses
Palpate frontal sinuses by pressing upward just below
eyebrows; note tenderness.
■ Palpate maxillary sinuses by pressing below eyes;
note tenderness.
■ No tenderness.

37. A B -NORMAL
■ TENDERNESS: MAY INDICATE INFECTIOUS OR
ALLERGIC SINUSITIS
PERCUSSION OF THE SINUSES
Percuss frontal sinuses with direct or immediate
percussion above eyebrows.
Percuss maxillary sinuses with direct or immediate
percussion below eyes.
No tenderness. Resonant tone.

38. ■ABNORMAL
TENDERNESS: SUGGESTS SINUSITIS.
DULL TONE: INDICATES THICKENING OR FULLNESS OF SINUS CAVITY
OR CAVITIES, ASSOCIATED WITH CHRONIC OR ACUTE SINUSITIS.

39. INSPECTION OF THE NOSE:
External Nose
■ Note size, shape, and symmetry.
■ Midline placement. Shape symmetrical and
consistent with age, gender, and race/ethnic group.
■ No nasal flaring.
■ No drainage

40. A B N O R M A L F I N D I N G S / R AT I O N A L E
■ Misalignment of nose or shape inconsistent with patient’s
biographical information: Previous trauma, congenital
deformity, surgical alteration, or mass. Abnormal shape also
associated with typical facies, including acromegaly or Down
syndrome.
■ Nasal flaring: Suggests respiratory distress, especially in
infants, who are obligatory nose breathers.
■ Clear, bilateral drainage: Allergic rhinitis.
■ Clear, unilateral drainage: May be spinal fluid as a result of
head trauma or fracture.
■ Clear, mucoid drainage: Viral rhinitis.
■ Yellow or green drainage: Upper respiratory infection.
■ Bloody drainage: Trauma, hypertension, or bleeding
disorders

41. Internal Nasal Mucosa:
Tilt head back and use nasoscope or penlight to inspect
nasal mucosa.
■ Pink, variations consistent with ethnic group/race and
with oral mucosa.
■ Moist, with only clear, scant mucus present.
■ Intact, with no lesions or perforations.
■ No crusting or polyps.
■ Septum located midline.

42. A B N O R M A L F I N D I N G S / R AT I O N A L E
■Bright red mucosa: Inflammation from rhinitis or
sinusitis; also suggests cocaine abuse.
■ Pale or gray mucosa: Allergic rhinitis.
■ Copious or colored discharge: Allergic or infectious
disorder, epistaxis, head or nose trauma.
■ Clustered vesicles: Herpes infection.
■ Ulcers or perforations: Chronic infection, trauma, or
cocaine use.
■ Dried crusted blood: Previous epistaxis.
■ Polyps (elongated, rounded projections): Allergies,
irritation or chronic infections.
■ Deviated septum: Normal variant or following
trauma.

44. ALERT
A DEVIATED SEPTUM IS CAUSE FOR CONCERN IF
BREATHING IS OBSTRUCTED
Turbinates
Inspect the turbinates. The middle turbinate is located
more medially, the inferior turbinate is more lateral, and
the superior is not visible.
Medial and inferior turbinates visible, symmetrical and
shape/size consistent with general features of patient.
Overlying mucosa coloring consistent with other
mucous membranes.

45. R AT I O N A L E / S I G N I F I C A N C E
■ Enlarged, boggy turbinates: Allergic disorder.
■ Pale or gray mucosa overlying turbinates: Allergic
disorder.

46. PALPATION OF THE NOSE
External Nose
Occlude each nostril and note patency.
■ Cartilaginous portion is slightly mobile. Nontender, no
masses. Nares patent
A B N O R M A L F I N D I N G S / R AT I O N A L E
■ Deviations or masses: Previous trauma or infection.

47.  Because the mucous membranes reproduce cells
rapidly, mouth lesions tend to heal quickly with
treatment. Therefore any persistent lesion requires
medical attention. Be aware of the possibility of oral
cancer.

48. INSPECTION OF THE MOUTH AND THROAT
Lips:
■Inspect color, condition, lesions, odor.
■ Midline, symmetrical, skin intact, pink, and moist.
■ Coloring consistent with ethnic group/race.
■ No unusual odors

49. A B N O R M A L F I N D I N G S / R AT I O N A L E
■ Asymmetry of placement: Congenital deformity,
trauma, paralysis, or surgical alteration.
■ Pallor: Anemia.
■ Redness: Inflammatory or infectious disorder.
■ Cyanosis: Vasoconstriction or hypoxia.
■ Lesions: Infectious or inflammatory disorder.
■ Cheilitis (inflammation of lips), drying, and
cracking: Dehydration, allergy, lip licking.
■ Cheilosis (fissures at corners of lips): Deficiency of B
vitamins or maceration related to overclosure.
Chancre: Single, painless ulcer of primary syphilis.
■ Angioedema: Allergic response.
■ Herpes simplex (clustered area of fullness/nodularity that forms
vesicles, then ulceration): Herpes viral infection.
■ Halitosis: Infections or gastrointestinal problems.

51. Cheilosis

52. ■ Angioedema: Allergic response.
■Herpes simplex (clustered area of
fullness/nodularity that forms vesicles, then
ulceration): Herpes viral infection.
■ Halitosis: Infections or gastrointestinal problems.


53. Teeth and Bite:
Have patient open and close mouth. Note occlusion and
number, color, condition of teeth.
■ Most adults have 28 teeth, or 32 if the four third molars,
or wisdom teeth, are erupted. (However, they are
usually impacted or extracted.)
■ Teeth should be white, not loose, with good occlusion,
and in good repair.

54. ■ Various abnormalities include loose, poorly
anchored teeth, malalignment, dental caries.
Discoloration of teeth: Chemicals or medications
(tetracycline may discolor teeth gray if administered
before puberty).
■ Mottled enamel: Fluorosis (excessive fluoride).
Dental caries
Malocclusion
Fluorosis
Tetracycline staining

55. Oral Mucosa and Gums:
ASSESSMENTTECHNIQUES/NORMAL
VA R I AT I O N S
■ Inspect color, condition, lesions of mucosa.
■ Note condition of gingiva, bleeding, retraction, or
hypertrophy.
■ Pink, moist, intact mucosa. Color variants acceptable if
consistent with patient’s ethnic group/race for instance,
dark stippling in dark-skinned patients.
■ Gums consistent in color with other mucosa and intact,
with no bleeding.

56. Gum hyperplasia: Side effect of medications, such as
dilantin or calcium channel blockers.
Gum recession or inflammatory gum changes
(gingivitis/ periodontal disease): Poor dental hygiene
or vitamin deficiency.Gingival recession Chronic gingivitis
Leukemia.

57. ■ Pale or gray gingivae: Chronic Gingivitis
■ Abrasions, erosion of underlying mucosa: In denture
wearers, poorly fitted dentures. Inflamed, bleeding
gingivae may also be seen with leukemia and human
immunodeficiency virus (HIV).

58. Hard and Soft Palate:
Inspect color and condition of hard and soft palate.
Palate intact, smooth, pink.
■ Bony, mucosa-covered projection on the hard palate or on
floor of mouth are normal variations.

59. A B N O R M A L F I N D I N G S / R AT I O N A L E
■ Perforation: Congenital or from trauma or drug use.
Cocaine use, HIV palatal candidiasis

60. Salivary Ducts:
■ Stensen’s duct: Inspect inner aspect of cheek (buccal
mucosa) opposite the second upper molar.
■ Wharton’s duct: Have patient lift tongue
and inspect the floor of mouth.
Stensen’s duct intact at buccal mucosa at level of second
molars.
■ Wharton’s duct intact at either side of frenulum.
■ Both ducts with moist and pink mucosa; no lesions,
swelling, or nodules.

62. A B N O R M A L F I N D I N G S / R AT I O N A L E
■ Fullness or inflammatory changes of glands: Blockage of
duct by calculi, infection, malignancy. Parotitis is
inflammation of parotid glands, (Parotitis;

63. Tongue:
Inspect color, texture, moisture, and mobilityPink and moist.
■ Coloring may vary consistent with ethnic group/race.
■ Mucosa intact with no lesions or discolorations.
■ Papillae intact. Tongue is freely and symmetrically mobile.
■ Geographic tongue is a normal variation.

64. A B N O R M A L F I N D I N G S / R AT I O N A L E
Absence of papillae, reddened mucosa, ulcerations:
Allergic, inflammatory, or infectious cause.
■ Color changes: May indicate underlying problems; for
example, red “beefy” tongue is seen with pernicious anemia.
Black, hairy tongue: Fungal infections.
 Hypertrophy and discoloration of papillae:Antibiotic use.
■ Reddened, smooth, painful tongue, with or without
ulcerations (glossitis): Anemia, chemical
irritants, medications.
■ Cancers may form on the tongue and on other oral mucosa.

65. Red, beefy Black, hairy
tongue tongue
Cancer of the tongue
Glossitis

66. Oropharynx:
Inspect oropharynx for color, lesions, and drainage.
Mucosa is pink, moist, intact. The lymphoid-rich
posterior wall may have a slightly irregular surface.
No lesions, erythema, swellings, exudate, or discharge.

67. A B N O R M A L F I N D I N G S / R AT I O N A L E
■ Yellowish or green streaks of drainage on the
posterior wall: Postnasal drainage.
■ Gray membrane/adherent material: Diphtheria.
■ White or pale patches of exudates with erythemic
mucosa: Infection, including streptococcal bacterial
infection or mononucleosis viral infection. Gonorrhea
and chlamydia are also associated with exudative
pharyngitis.
■ Erythema: Inflammatory response, typically associated
with infectious pharyngitis; also common in smokers.
■ Scattered vesicles/ulcerations: Herpangioma.

69. Tonsils:
Locate tonsils posterior to arches on sides of throat.
■ Note color, size, and exudate.
■ Symmetrical, pink, clean crypts.

70. A B N O R M A L F I N D I N G S / R AT I O N A L E
■ Bulges adjacent to the tonsilar pillars: Potential
peritonsillar abscess.
■ Reddened, hypertrophic tonsil, with or without
exudates: Acute infection or tonsillitis.

71. Uvula:
■ Have patient say “AH!” and note symmetrical rise of the
uvula.
■ Midline, pink, moist, without lesions.
■ Symmetrical rise of the uvula
Abnormal variation
 Erythema, exudate, lesions: Infectious process.
 ■ Asymmetrical rise of the uvula: Problem with CN
IX and CN X

73. PALPATION OF THE MOUTH AND THROAT
Lips:
Lightly palpate lips for consistency and tenderness.
■ Soft, nontender, no masses.
■Areas of induration, thickening, nodularity, or
masses: Neoplasm.
■ Tender induration that soon develops vesicles:
Herpes simplex.


74. Tongue:
Lightly palpate tongue for consistency and tenderness.
■ Tissue is soft, without masses, nodules, thickenings, or
tenderness.
■ Tissue is soft, supple, without
nodules, thickenings, masses, or tenderness. Sublingual
glands may be palpable under the tongue but should be
nontender, soft, and supple
A B N O R M A L F I N D I N G S / R AT I O N A L E
■ Areas of induration, thickening, nodularity: Potential
malignancy.
■ Areas of unexpected induration, thickening, nodularity
or other mass: Malignancy

75. Glands (Parotid, Submandibular, and Sublingual):
Parotid: Palpate in front of ears.
Submandibular and sublingual: Palpate under the
mandible.
Parotid glands are nonpalpable and nontender.
Submandibular and sublingual glands may be palpable but
should be nontender, supple, and soft.

76. A B N O R M A L F I N D I N G S / R AT I O N A L E
■ Enlarged, tender parotid glands: Parotitis, blocked
ducts, infection, or malignancy.

77. INSPECTION OF THE NECK
Inspect neck in neutral and hyperextended positions and as
patient swallows.
Neck erect, midline, no lumps, bulges, or masses.
■ Thyroid not visible. No masses, swelling, or hypertrophy in
mid to lower half of anterior neck.
a- Inspecting the neck from the neutral position
b- Inspecting the neck when hyperextended
c- Inspecting the neck when the client swallows water

78. A B N O R M A L F I N D I N G S / R AT I O N A L E
■Enlargements: Lymphadenopathy, lymphoma, or other
malignancy.
Torticollis (deviation of neck to one side caused by
spasmodic contraction of neck muscles): Scars,
tonsillitis, adenitis, disease of cervical vertebrae, enlarged
cervical glands, cerebellar tumor, rheumatism
retropharyngeal abscess.
■ Enlarged, visible thyroid: Goiter or malignant mass.

79. HELPFULHINTS
Lymphatic tissue is largest in childhood and decreases in size
with age. Normal palpable nodes are more likely to be
found in children than in adults.
Patients who present with a sore throat often complain about
“swollen glands.” They are actually feeling their
submandibular salivary glands.
To distinguish between salivary glands and lymph nodes,
remember: A normal lymph node is either small (_1 cm),
round, soft to rubbery, movable, and nontender or
tender and enlarged with infection.
Submandibular glands are larger, soft, glandular, and not
freely movable.
A palpable normal node is more likely to be a superficial node
than a deep cervical one. Deep cervical nodes are normally
nonpalpable.

81. PALPATION OF THE NECK
Neck:
■ Use light palpation and check for masses or areas of
tenderness.
■ Supple, nontender, no masses.
A B N O R M A L F I N D I N G S / R AT I O N A L E
■ Masses: Lymphadenopathy, maligna

90. ASSESSING THE EYE AND THE EAR
 The primary function of the eye is vision, including central
and peripheral vision, near and distance vision, and
differentiation of colors.
 To accomplish these tasks, the external and internal
structures of the eye work together to receive and transmit
images to the occipital lobe of the brain for interpretation.
 Visual difficulties can result from disease or injury to any
of the structures involved in the visual pathway.

140. UNDERSTANDING SOUNDS AND SOUND WAVES
 Hearing occurs by air conduction and bone conduction of
sound waves. Sound waves are characterized by
differences in pitch and loudness
 Frequency, the number of sound waves per second,
determines the pitch of the sound.


155. THANK YOU