25 Examination of the Head and Neck
There have been substantial transformations to the diagnosis and treatment of head and neck diseases, with technical advances in equipment available and clinical approach, and these are now manifest in modifications of the examination. Examination of the head and neck was often described as an ‘examination of the throat’. Throat is a vague term, usually implying the laryngopharynx. Fibre-optic endoscopy has almost completely replaced indirect laryngoscopy with a mirror in all but some developing countries. The scope of head and neck surgery has become far more wide-ranging and encompasses not only pharyngolaryngeal disease, but also salivary gland disease, thyroid disorders and a variety of symptoms which present to ‘Target’ (otherwise called 2-week cancer wait) clinics.
The symptoms associated with throat disease include hoarseness, dysphagia, odynophagia, sore throat, lump in the throat, (referred) otalgia, cough, lump in the neck and weight loss. Common findings on examination are vocal cord palsy, vocal cord oedema, vocal cord polyps, vocal cord nodules, laryngeal papilloma, occasionally patients with a neoplasm and laryngectomy patients. Patients with metastatic neck nodes may be used in the head and neck clinical examination, but benign problems are commoner subjects, including salivary gland tumours, thyroid nodules and neurovascular lesions (e.g., carotid body tumours). Other than examinations which have simulation, it is more likely that candidates will be given an external sign or lump to evaluate rather than a case that requires endoscopic evaluation.
The technique outlined in this topic is ideal for a long case but may need to be modified for a short case. Listen carefully to the examiner’s instructions and do what is asked. Do not irritate the examiner by examining parts of the patient that have not been mentioned. However, if in doubt, it is better to be thorough.
Be bare below the elbows and make sure that you are seen to have washed your hands prior to engaging with the patient. Introduce yourself and clearly explain to the patient what you have been asked to do and for their permission to proceed. Be polite and have a reassuring demeanour. It may be necessary to wear gloves depending on the examination required (e.g., bimanual examination of the oral cavity) and these will be readily available.
An electric headlight will usually be available and can be used. The surgeon should sit with his or her knees together and the legs to the right side of the patient’s. Ask edentulous patients to remove their dentures. Expose the whole of the neck up to and including the clavicles. Remove any neck scarf which may hide a wound or stoma. It is surprising how many times candidates do not follow this simple advice and miss important pathology.
25.2 Oral Cavity
Inspect the lips for perioral lesions. Ask the patient if there is any tenderness in the mouth. Take two metal tongue depressors and insert them to retract the buccal mucosa on each side. Ask the patient to protrude the tongue and move it from side to side and then up to the palate and down. This should allow an inspection of the dorsal and ventral surfaces of the tongue, the tongue’s lateral borders, and the floor of the mouth; it also tests hypoglossal nerve function. Pay attention to the retromolar trigone area. The two tongue depressors are then used to examine the buccal mucosa, teeth and alveolar ridges, and the opening of the parotid ducts opposite the upper second molar.
Dispense with one of the tongue depressors and use the other to depress the tongue. Check over the palate, the tonsils and the posterior pharyngeal wall. Ask the patient to say ‘aah’ and check movement of the palate. Remove the tongue depressor and put a glove on. Bimanually, palpate the floor of the mouth overlying the submandibular duct for calculi or masses. Palpate the base of the tongue, as a tumour in this site may not be visible but easily palpable.