8 Focused Assessment- HEENT

Learning Objectives

At the end of this chapter, the learner will:

  1. Obtain a health history related to the head, eyes, ears, nose and throat (HEENT).
  2. Perform a physical assessment of the body systems that make up HEENT using correct techniques.
  3. Document findings of the HEENT and neck exam.

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

The assessment of the HEENT systems will include examinations of the head, eyes, ears, nose, and throat/neck.  The HEENT examination will include assessing the HEENT for symmetry, and color; hair distribution to scalp, eyebrows, and eyelashes; hydration status of the mucus membranes to the nose and mouth; the number and condition of teeth, palate structure and uvula placement and color of lips and buccal membrane. Included in the assessment are the XII cranial nerves.

The examination of the HEENT systems will be completed by inspecting and palpating the head, eyes, ears, nose, throat/neck, lymph nodes, and testing the cranial nerves that innervate the function of each organ/structure of HEENT.

 

II. Anatomy and Physiology

Click the links below to review anatomy and physiology of the HEENT system. In the assessment process, you will need to apply your knowledge of the A & P to the HEENT system.

Watch and learn from the following videos:

Please use this link if the Youtube is not visible Landmarks of the Head and Neck

Anatomy of the muscle of the Head and the Neck. If the picture is not visible click the link: https://psychology.wikia.org/wiki/Zygomaticus_major_muscle

Anatomy of the Head and Neck muscles
Anatomy of the Head and Neck muscles

If the picture below is not visible click on the link: Structures and functions of the eyes

File:1413 Structure of the Eye.jpg

Anatomy of the Ear: If the picture below is not visible click on the link: https://commons.wikimedia.org/wiki/File:Anatomy_of_the_ear.jpg

Anatomy of the external and internal ear
Anatomy of the external and internal ear

If the picture below is not visible then click on this link: Anatomy of the Nose

Anatomy of the nose
Anatomy of the nose

Anatomy of the Oral cavity  If the picture is not visible click on this link: https://en.wikipedia.org/wiki/Mouth_assessment

Mouth - oral cavity
Mouth – oral cavity

Anatomy of the Lymph Nodes to the Head and Neck if the  picture is not visible click the link: https://medika.life/the-lymph-nodes/

Human Anatomy-the lymph nodes to the head and neck
Human Anatomy-the lymph nodes to the Head and Neck

Cranial Nerve Function-This is discussed in more detail in the Neurological chapter.

Number​
Mnemonic​
Cranial Nerve​
Function (S/M/B)​
Mnemonic​

I​

On​

Olfactory​

Smell (S)​

Some​

II​

On​

Optic​

Vision (S)​

Say​

III​

On​

Oculomotor​

Eye Movements (M)​

Marry​

IV​

They ​

Trochlear​

Eye Movements (M)​

Money​

V​

Traveled​

Trigeminal​

Sensory/motor – face (B)​

But ​

VI​

And​

Abducens​

Eye movements (M)​

My​

VII​

Found​

Facial​

Motor-face, Taste (B)​

Brother​

VIII​

Voldemort​

Vestibulocochlear (Auditory)​

Hearing/Balance (S)​

Says​

IX​

Guarding​

Glossopharyngeal​

Motor – throat Taste (B)​

Big​

X​

Very​

Vagus​

Motor/sensory – viscera (autonomic) (B)​​

Bucks​

XI​

Ancient​

Accessory​

Motor-head &neck (M)​

Mean​

XII​

Horcruxes ​

Hypoglossal ​

Motor-lower throat (M)​

More

Knowledge Check

 

 

III. Related Medical Terminology

Accommodation The eye’s lens’ ability to change shape in order to focus from distant to near or near to distant
Amblyopia Decrease vision to one eye only. Also called a lazy eye
Astigmatism There is a deviation in the curvature of the eye’s lens or cornea leading to distorted or blurry
Auricle The visible part of the auditory system also called the pinna or the ear
Blepharitis Bilateral Inflammation along the edges of the eyelids
Buccal Associated with the cheek
Candidiasis (Thrush) Candida is a yeast that causes a fungal infection to the mouth, throat, gut, vagina, and skin
Canthus  “The angle or corner on each side of the eye, formed by the junction of the upper and lower lids.”
Cataract The clouding of the eye’s Len causes blurred vision
Cerumen  Glands in the ear canal produce ear wax also called cerumen
Conjunctivitis Infection of the transparent membrane lining the outer layer of the eyelid and eyeball- Pink eyes
Diplopia An individual sees two images of the same thing also called Double vision
Tonsillar exudate Tonsils secrete fluid in response to an infection to the tonsils itself
Frenulum of the tongue A folded piece of tissue that connects the posterior center of the tongue to the mouth
Glaucoma Abnormally high pressure in the eyes damages the optic nerve which can lead to blindness.
Gingivitis “Mild and common gum disease.”
Glossitis  Inflammation of the tongue.
Myopia  Close objects are seen better than distant objects.
Normocephalic Normal size and shape of the head that is age-appropriate
Occipital Relate to or located to the back of the head
Oropharynx Includes the soft palate, side and back wall of the throat, tonsils, and back third of the tongue
Otorrhea Ear drainage/discharge
Periodontitis Gum disease
Photophobia Light sensitivity
Presbycusis Hearing loss mostly from aging
Ptosis Drooping of the eyelid
Rhinorrhea Excessive nasal drainage-runny nose discharge
Sclera The tough white outer coat covering approx. 5/6 of the posterior surface of the eyeball
Strabismus At least one eye muscle is weak causing the eyes not to line up in the same direction.
Tinnitus Ringing or other abnormal noises in one or both of your ears.
Xerostomia Dry mouth from a deficit of saliva production.

Knowlege Check

 

IV. Step by Step Assessment

  • Perform hand hygiene.
  • Check room for contact precautions.
  • Introduce yourself to the patient.
  • Confirm patient ID using two patient identifiers (e.g., name and date of birth).
  • Explain the process to the patient.
  • Assemble equipment prior to starting the exam.
  • Be organized and systematic in your assessment.
  • Use appropriate listening and questioning skills.
  • Listen and attend to patient cues.
  • Ensure patient’s privacy and dignity.
  • Apply principles of asepsis and safety.
  • Check vital signs.

HEENT Exam

Steps
 Additional Information
1. Conduct a focused interview related to HEENT and related diseases. Ask relevant questions related to:

pain to the head, eyes, ear, nose, throat and neck or drainage as applicable.

about changes to sight, smell, hearing, taste, chewing, swallowing and speech.

the need for glasses, hearing aids, dentures.

acute or chronic disease of the HEENT and medication used to treat mentioned disease or abnormalities.

risk factors noted to the HEENT systems.
2. Inspect: 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, sclera, and eye brows
  • Inspect pupil size and reaction to light.
  • image

Ears

  •  Inspect external appearance of ears including auricle, tragus, helix, and lobule

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

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)
3. Tests for assessment of the eys Pupillary reaction to light

Modeling Human Pupil Dilation to Decouple the Pupillary Light Reflex

https://www.degruyter.com/document/doi/10.1515/phys-2019-0047/html

Test pupil reaction directly and consensually

Test extraocular movements (CN III, IV, VI) while stabilizing the head so that all nine cardinal gazes are tested:

If the picture is not visible click on the link: https://youtu.be/GeQZlxACBY0

Examining extraocular movements - YouTube

If the picture is not visible click on the link: https://www.drawittoknowit.com/course/neuroanatomy/glossary/physical-exam/cardinal-positions-of-gaze

  • Cardinal Positions of Gaze (Extraoccular movements) - Neuroanatomy Flashcards | Draw it to Know it

Test for convergence by moving finger toward the bridge of the nose

 
Palpate/Tests to assess the ears https://youtu.be/ixOj-RkoxNA

 

 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
Palpate/Tests to assess the Nose
  • Nose Exam: https://youtu.be/5Sa5mmfy3Zs
  •  Palpate the frontal and maxillary sinuses to assess for tenderness
  • Sinus explorationhttps://youtu.be/paTlL9u735k
  • 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.
Palpate/Tests to assess the Mouth  

If the youtube above is not visible click on this link: https://youtu.be/gmJxLhCpCQw

 
Neck

Palpate/Tests to assess the Neck

 

 Neck and Lymph node assessment should include:

Thyroid examination: If the picture below is not visible click on this link: https://youtu.be/RfmO9k9neWM-this is actually a Youtube.

Examine thyroid gland

Thyroid examination
Thyroid examination

Lymph node examination

  •  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
HEENT exam If the youtube is not visible please click on this link: https://youtu.be/MkqCjH-BlMo

V. Documentation of Assessment Findings

A sample of the narrative documentation:

The Head is normacephalic and without lesions or bumps. Hair is thick and curly without patches or ball spots and the scalp is clean. The face is symmetrical and smooth.  Temporal pulse is palpable at 2/5 bilaterally.

Eyes are distantly placed and equal in size and shape with thick black eyelashes. Eyebrows are thick but tapered and well kept.  Eyelids in normal position with no abnormal widening or ptosis.  No redness, discharge, or crusting was noted on lid margins.  Conjunctiva and sclera appear moist and smooth.  Sclera white with no lesions or redness.  No swelling or redness over the lacrimal gland.  The cornea is transparent, smooth, and moist with no opacities, the lens is free of opacities.  Irises are round, flat, and evenly colored brown.  Pupils are equal in size and reactive to light and accommodation.  Pupils converge evenly. Extraocular movements were smooth and symmetric in all nine cardinal gazes with no nystagmus.   Vision is 20/20 via the Snellen Chart.

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.  A small amount of moist yellow cerumen in the external canal.  Whisper test: patient repeats 2 syllable words.

Lips pink, smooth, and moist without lesions.  The buccal mucosa is pink, moist, and without exudates.  Thirty-two white to yellowish teeth are present with no cavities noted.  Gums pink without redness or swelling.  The tongue protrudes to a normal distance without tremors, is midline, and is equal bilateral in strength.  Ventral surface of tongue smooth and shiny pink with small visible veins present.  Frenulum in the midline.  Soft palate smooth and pink.  Tonsillar pillars are pink and symmetric and Uvula is midline.

The nose is normal size but smooth, symmetric, and midline. Each nare is patent. The nasal septum slightly deviated to the left but does not obstruct airflow.  Inferior and middle turbinates are dark pink, moist, and free of lesions.  No purulent drainage was noted. Frontal and Maxillary sinuses are non-tender upon palpation.   The temporomandibular joint has full range of motion without tenderness or crepitus. Cranial Nerves II-XII are grossly intact.

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 the neck.  Thyroid gland nonvisible but palpable when swallowing.  Trachea in the midline.  Lymph nodes are nonpalpable.

 

VI. Related Laboratory and Diagnostic Procedures/Findings

CBC-complete blood count

BMP-Basic Metabolic Panel

Lipid panel including Total cholesterol. High-density lipoprotein cholesterol, Low-density lipoprotein cholesterol (LDL-C), and Triglycerides.

https://www.revieweducationgroup.com/ce/the-when-and-why-of-ordering-blood-work

Ear drainage culture https://www.ucsfhealth.org/medical-tests/ear-drainage-culture

Bleeding time: Pt, PTT, and INR.

CT Scan of the head/brain.

Direct laryngoscopy and Videostroboscopy. https://www.cancer.net/cancer-types/laryngeal-and-hypopharyngeal-cancer/diagnosis

A more detailed overview of putting the HEENT assessment together is seen on the following website: https://nextgencombatmedic.com/2017/04/06/neurological-assessment/

 

VII. Learning Exercises

After watching the HEENT assessment video above complete the following exercises:

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/

Surface anatomy landmarks of the head and neck (preview)Human anatomy Kenhub, January 31, 2019, Creative Commons Attribution 3.0 Unported license. Retrieved 20:08 July 27, 2021, https://youtu.be/b6O-TrwFor0

Main Muscles of the Head and Neck (preview)-Human Anatomy-Kenhub, January 27, 2020 Creative Commons Attribution 3.0 Unported license, Retrieved 20:08 July 27, 2021 https://youtu.be/lkt-8XcpHr0

Anatomy and Physiology-Sensory System. The eye, March 31, 2015 Creative Common, Retrieved 20:40 July 27, 2021 https://youtu.be/e0KmUctCErI

Anatomy of the Human Ear. June 25, 2016 Creative Common, Retrieved 20:40 July 27, 2021, https://youtu.be/3G5jiXl2LSM

Mouth (oral Cavit) Mouth Assessment-Wikipedia Retrieved 21:33 July 27, 2021 https://en.wikipedia.org/wiki/Mouth_assessment

The lymph nodes-Medika life: Understanding Human Anatomy Updated July 22, 2020, Retrieved 23:40 July 27, 2021, https://medika.life/the-lymph-nodes/

File: Anatomy of the ear.jpg Wikimedia commons Uploaded December 2, 2020 Retrieved 24:21 July 28, 2021 https://commons.wikimedia.org/wiki/File:Anatomy_of_the_ear.jpg

Douglas College Human Anatomy and Physiology (1st ED.) BC CAmpus 11.3 Axial Muscles of the Head, Neck, and Back Retrieved 01:21 July 7-28-2021, https://pressbooks.bccampus.ca/dcbiol11031109/chapter/11-3-axial-muscles-of-the-head-neck-and-back/

Zygomaticus major muscle-Psychology Wiki-Fandom, Muscle of the Head and Neck Retrieved 01:27 July 28, 2021 https://psychology.wikia.org/wiki/Zygomaticus_major_muscle

Clinical Examination of the Musculoskeletal system. Open Library Pressbooks Cranial Nerves. Retrieved 01:27 July 28, 2021 https://ecampusontario.pressbooks.pub/clinicalexamination/chapter/neurological-assessment/

Mouth exam -ENT Oxford Department of ENT February 17, 2012, Retrieved July 28, 2021, https://www.youtube.com/watch?v=gmJxLhCpCQw

The Thyroid Exam and Physical Diagnosis of Thyroid Disease November 6, 2014, Retrieved July 28, 2021, https://youtu.be/RfmO9k9neWM

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Health Assessment Guide for Nurses Copyright © by Ching-Chuen Feng; Michelle Agostini; and Raquel Bertiz is licensed under a Creative Commons Attribution 4.0 International License, except where otherwise noted.

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