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, 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, and lymph nodes.
  • The HEENT examination also includes testing the cranial nerves that innervate and/or affect the function of each organ/structure of HEENT system.

 

II. Anatomy and Physiology (A&P)

The assessment process includes applying previously learned Anatomy and Physiology to the HEENT system.

The video and pictures below will assist with the review:

Please use this link if the Video 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

Structure of the Eye.

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  

Lymph nodes are small structures that are part of the lymphatic system. These nodes act like a guard station along lymphatic tracts allowing the filtering of lymph to detect foreign substances, damaged cells or cancer cells. These detected abnormal cells are then destroyed or removed from circulation by the immune system.

  • Lymph nodes are located along lymphatic tracts all over the body but are more densely concentrated in the cervical (neck), axillary (armpit), and inguinal (groin) regions.
  • Lymph nodes become inflamed or enlarged in various diseases, which may range from mild throat infections to life-threatening cancers.

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

Abnormal Lymph Nodes:

Abnormal lymph nodes at the axillary area of a breast

Author: www.scientificanimations.com

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

Anatomical landmarks,

tests, and abnormalities

 Definitions/locations/explanation
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/Health history related to HEENT and related diseases. Ask relevant questions to obtain subjective data related to HEENT:

  • Pain- Are you having any pain to the head, eyes, ear, nose, throat, and/or neck?
  • Drainage or Secretions- Are you having any drainage to the head, eyes, ear, nose, throat, and neck?
  • Changes -Have you noticed any changes to sight, smell, hearing, taste, chewing, swallowing and speech?
  • Are glasses, dentures, and/or hearing aids used?
  • Acute verses Chronic diseases related to HEENT-Is there a history of diseases related to HEENT or are the  complaint3 related to HEENT new (less than three month)?
  • Medications-Are medications being taken to address new or chronic HEENT conditions/abnormalities/diseases?
  • Risk Factors-Has the health history revealed any risk factors to the HEENT system?
2. Inspect the eyes, ears, nose, and throat/neck: Head

  • Inspect hair for quantity, distribution, texture, pattern of loss
  •  Inspect scalp and face for asymmetry, involuntary movements, edema or masses
  • Inspect the head for size-Macrocephalic (Hydrocephalic-large skull), Normacephalic, or Microcephalic (Zica-small skull)

Eyes

  • Inspect general appearance of eyes including lids, lashes, conjunctiva, sclera, and eye brows
  • Inspect pupil size, shape, reaction to light, and accommodation (PERRLA)
  • Grading Pupil Size

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
  • 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)
3. Assessment of the Eyes The hands on examination of HEENT includes the following Tests/Procedures:

Eyes:

Tests used to assess eye movements and pupil changes:

  •  Determine pupil size bilaterally and compare for equality
  •  Test pupillary reaction to light (CN II, III) directly and consensually.
    • Pupils should constrict in both eyes at the same time.

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

Modeling Human Pupil Dilation to Decouple the Pupillary Light Reflex

 

  • Test for Pupil Accommodation Reflex:-this test depth perception, reading ability, and near work- have the patient look at a distant object and then quickly at a target near your nose. Observe if pupils constrict (shrink) and eyes converge (turn inward)
  • Test for convergence-assesses how well the eyes work together to focus on a near object-move an object towards the bridge of the nose until double vision is reported

Putting all above test together:

The next test assesses the muscles of the eyes. These movement are called extraocular movements  and are controlled by (CN III, IV, VI). This test can be completed either using an H or Pie pattern while having the patient stabilize the head

  • Testing Extra-Occular/Cardinal gazes using the pie technique

https://medical-dictionary.thefreedictionary.com/_/viewer.aspx?path=MosbyMD&name=cardinal-position-of-gaze.jpg&url=http://medical-dictionary.thefreedictionary.com/cardinal%2Bposition%2Bof%2Bgaze

  • Testing Cardianl gazes also called Extra Occular Movement using the H technique

Test extraocular movements (CN III, IV, VI) while stabilizing the head so that all nine cardinal gazes are tested using the H method: https://morancore.utah.edu/basic-ophthalmology-review/the-motility-exam/

While testing the Extraocular movement also called the cardinal Gauzes the eyeball may shake. This is called a Nystagmus and may be normal or maybe an abnormality.

 

Assessing Vision:

  • 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

 

https://youtu.be/NhzBjm1xAnk
4. Assessment of the ears 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)

 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

https://youtu.be/ixOj-RkoxNA
Assessment of the Nose, Sinuses, and Neck/Trachea The Nose

Inspection:

  • Inspect the external surface of the nose for symmetry and color.
  • Inspect the contour of the nose for swelling, and malformations such as masses and lesions.
  • Inspect the nasal cavity and mucosa of the nose for color, discharge/bleeding, swelling, foreign bodies, and malformations.

Healthcare provider has gloved thumb on clients nose and fingers on forehead to look into the nasal cavity. Client's head is tilted slightly back.                    Assessing the nose-Inspecting the interior nose and Septum

Inspecting the nasal cavity and mucosa. Screenshots from the video Inspection of the Nose and Nasal Cavity by opennursing, licensed under Creative Commons Attribution.

Palpation

Gently, palpate the external nose if trauma/injury or lesions are present.

  • Use the thumb and the index finger to palpate the contour.
  • Lesions can be palpated with the index finger.
    • Note the consistency of lesions (e.g., soft or firm?).

Palpate the nose for airflow/patency.

  • Occlude one naris at a time while asking the patient to take a deep and quick inhalation in through the nose (like a sniff inwards as if trying to smell something).
    • The patient should be able to breathe inwardly without difficulty
  • Assess the sense of smell by performing 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.

Sinuses

Palpation:

Gently palpate one sinus at a time.

  • Use a circular motion to palpate.
  • Begin with the frontal sinuses- inferior to the eyebrows over the bony ridge. Avoid the eye socket.
    • Inquire if the patient had any pain and/or tenderness upon palpation.
      • A slight pressure is normal. If pain/tenderness is present, assess further subjectively.
    • Putting together assessing Head, Face, and sinuses
    • Then, palpate the maxillary sinuses inferior to the zygomatic bone slightly lateral to the nose

 

Putting Head, Face, and Sinus assessment together:

https://youtu.be/cEkXycKALpI
Assessing the Mouth The inspection part of the assessment was discussed above but is placed here again to assist with learning.

  • 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)

Putting together the Nose, Mouth, and Throat assessment:
Neck

Palpate/Tests to assess the Neck

 

 Neck and Lymph node assessments

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

Examine thyroid gland

Thyroid examination
Thyroid examination

 

Trachea examination/assessment

Inspect the trachea in the neck region for alignment.

  • Normally the position of the trachea is midline without deviation. Deviation of the trachea from its midline position in the neck is a CRITICAL CLINICAL SIGN may indicate pneumothorax, lung collapse, or other pathologies requiring immediate interventions.

Trechea deviation

Lymph node examination/assessment

  • 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:

Anatomy & Physiology. (2015, March 31). Sensory system: The eye [Video]. YouTube. Sensory system: The eye [Video].

Anatomy & Physiology. (2016, June 25). Anatomy of the human ear [Video]. YouTube. Anatomy of the human ear

Cleveland Clinic. (n.d.). What are lymph nodes? What are lymph nodes?

College of DuPage. (n.d.). Inspection and palpation of nose and sinuses. In Nursing physical assessment. Inspection and palpation of nose and sinuses

Daniel, M., Rougas, S., Warrier, S., Tabaddor, R., Bray, K., & Taylor, J. (2015). Teaching physical exam skills to novices: Developing all the tools in the clinician toolbox. MedEdPORTAL, 11, 10057. Teaching physical exam skills to novices: Developing all the tools in the clinician toolbox.

Douglas College. (n.d.). Axial muscles of the head, neck, and back. In Human anatomy and physiology. BCcampus. Axial muscles of the head, neck, and back

Fandom contributors. (n.d.). Zygomaticus major muscle. Psychology Wiki. Zygomaticus major muscle.

Kenhub. (2019, January 31). Surface anatomy landmarks of the head and neck [Video]. YouTube. Surface anatomy landmarks of the head and neck [Video]

Kenhub. (2020, January 27). Main muscles of the head and neck [Video]. YouTube. Main muscles of the head and neck [Video]

Medika Life. (2020, July 22). The lymph nodes: Understanding human anatomy. The lymph nodes: Understanding human anatomy

Minnesota State. (n.d.). Lymph node tutorial. Lymph node tutorial.

Open Library Pressbooks. (n.d.). Cranial nerves. In Clinical examination of the musculoskeletal system. Cranial nerves. In Clinical examination of the musculoskeletal system.

OpenStax. (2013, June 19). External nose [Image]. Wikimedia Commons. External nose

Pressbooks. (n.d.). Overview of focused assessment of the head, eyes, ears, nose, and throat (HEENT). Overview of focused assessment of the head, eyes, ears, nose, and throat (HEENT)

RegisteredNurseRN. (n.d.). Head and neck assessment nursing [Video]. YouTube. Head and neck assessment nursing

Scientific Animations. (n.d.). Swollen lymph nodes [Image]. Swollen lymph nodes

Swift, H. (2013, October 24). Charting example for physical assessment. Charting example for physical assessment

The Free Dictionary. (n.d.). Cardinal position of gaze [Image]. Cardinal position of gaze

University of Oxford Department of ENT. (2012, February 17). Mouth exam [Video]. YouTube. Mouth Exam

University of Utah. (n.d.). The motility exam: Cardinal gaze positions. Cardinal gazes/Extra Occular Movement exam

U.S. National Library of Medicine. (n.d.). MedlinePlus. Cardinal Gazes/Extra Occular movement exam

Wikimedia Commons contributors. (2020, December 2). Anatomy of the ear [Image]. Anatomy of the ear

Wikimedia Commons contributors. (n.d.). Structure of the eye [Image]. Structure of the eye

Wikipedia contributors. (n.d.). Lymph node. Wikipedia. Lymph node assessment

Wikipedia contributors. (n.d.). Mouth assessment. Wikipedia. The mouth assessment

YouTube. (2014, November 6). The thyroid exam and physical diagnosis of thyroid disease [Video]. The thyroid exam

YouTube. (n.d.). Convergence insufficiency: Easy at-home screening [Video]. Convergence insufficiency- Testing convergence as part of the eye exam-CN II,IV, VI

YouTube. (n.d.). Ear: Inspection and palpation of external ear [Video]. Ear Exam

YouTube. (n.d.). Head, face, and sinuses [Video]. Visual acuity test with snellen exam

YouTube. (n.d.). Mouth examination – ENT [Video]. Mouth Examination

YouTube. (n.d.). Nose, mouth, and throat assessment [Video]. Nose, Mouth, and Throat assessment-video

YouTube. (n.d.). Pupillary assessment (PERRLA) [Video]. Pupillary assessment of the eye

YouTube. (n.d.). Visual acuity test with Snellen eye chart exam [Video]. Using the snellen chart to test vision

 

 

License

Icon for the Creative Commons Attribution 4.0 International License

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.

Share This Book