A big portion of a routine physical exam, the HEENT exam overlaps a bit with the cranial nerve exam (which has been given its own page for the sake of simplicity). After learning each one in isolation, one can spend some time thinking about how to organize these different exam units together in an intuitive manner.
As the acronym suggest, the HEENT exam has a few major components:
- Head (inspection, palpation, and testing of cranial nerves)
- Eyes (inspection)
- Ears (inspection, hearing test of cranial nerve)
- Nose (inspection)
- Throat (inspection, palpation)
As stated previously, much of this component of the HEENT exam is covered in the cranial nerve exam. With that in mind let us review some of the basics here:
As is the case with many different exam components, we must first use our eyes to assess for any obvious findings. Some questions to ponder are:
- What is the general appliance of the patient?
- Does their face have symmetry? Any facial drooping?
- Are there any stark findings such as ptosis or a goiter?
Sinus palpation: apply pressure to the patients sinuses in order to assess for any pain. Pain can suggest a possible underlying infection.
Much of this section is covered in the cranial nerve exam (CN II, III, IV, VI specifically). Here are the other components of how we examine a patient’s eyes.
External inspection: all components of the eyes that are externally visible should be inspected. Look out for jaundice, bleeding, infection, inflammation, and really anything that is out of the ordinary.
Red reflex: using an ophthalmoscope you can shine the light in a patients eyes and visualize the “red reflex” in both eyes. The wrong color in this reflex can indicate serious conditions.
Fundus exam: using an ophthalmoscope, one can look at the structures in the back of the eye. Realistically this is very difficult to do properly (especially without dilating the patient) and other instruments are better suited for this procedure (an ophthalmology consult should be called in many situations for further investigation of the fundus).
That being said it is good to have some perspective on what a normal fundus looks like. For the sake of simplicity we will not go too into detail on this section of the exam.
Hearing test: often times a bilateral finger rubbing test is used to screen for hearing loss. Refer to the cranial nerve exam (CN VIII) for specifics on using tuning forks for further investigation of hearing loss.
External inspection: When moving onto the ear component of the exam, begin again with general inspection. Without using an otoscope you should be able to observe the auricle and external auditory canal.
While we may take for granted that the external anatomy of the ear will often be normal, in some cases underlying diseases will present with findings in this region. Infection and even shingles can be observed in this component of the exam.
Otoscopic examination: using an otoscope, we are able to observe the internal structures of the ear. Some basic tips for using the otoscope: hold the scope near the head, pull back on the ear you are examining with the hand that is not holding the otoscope (in order to straighten the ear canal), and brace your pinky agains the patient’s skull (to avoid rapid movements that will cause the scope to go too deep into the canal). There are a variety of different findings that can be observed, however we generally are looking to see a non diseased inner ear canal, and intact tympanic membrane.
Sense of smell: this can be assessed by asking the patient if they have observed any issues with their sense of smell. If further investigation is required refer to the cranial nerve exam page (CN I specifically)
External inspection: beginning with the external inspection we can appreciate large scale abnormalities of the nose (and can also hear things such as a runny nose, etc).
Internal inspection: using the otoscope, we are also able to look directly in the nasal canal for any abnormal finings.
The sub classification of exam components such as the oral cavity are not worth stressing over (does it go under “head” vs. “throat”?) With this in mind, it is more important to consider how inspection of the oral cavity will fit into your exam “flow”. Give that we unavoidably have access to the oral cavity for the internal throat exam, we chose to include this section under the throat component of the HEENT exam.
External inspection of mouth: are the lips cracked? Any external findings? Make sure to ask the patient more about any finding and properly characterize it.
Inspection of oral cavity: visually we can look for any abnormal findings within the oral cavity. Make sure to look behind the lips and under the tongue as well! There are many findings that are too numerous to go over here. At the very least if you find anything that is out of the ordinary, ask the patient about it, characterize it (any pain, what does it look like, where is it, etc.) and follow up!
*You can use this as an opportunity to ask the patient if they have access to routine dental care!
Palpation of the oral cavity: if time allows, or unusual findings suggest the need to do so, gloving up and palpating within the oral cavity (under the tongue as well) can be informative.
*Further more there can be external manifestations of pathologies that reside within the oral cavity!
Oropharynx: looking in the back of the throat, with help of a tongue depressor can be very useful and informative.
*Some findings can also narrow down the possible diagnosis (such as exudative pharyngitis which usually is associated with either EBV infection or strep throat).
Neck exam: beginning initially with inspection, we can also palpate any abnormal findings we come across. Lymph nodes are one example of structures we want to palpate for (even if nothing is seen visibly). We are looking to find any unusual manifestations (enlarged size, abnormal feel/rigidity, pain).
Thyroid test: while realistically an ultrasound (and further imaging) will be more informative if we suspect abnormalities with the thyroid, in the absence of a clear goiter, we can palpate the thyroid in the following manner.
- Stand behind the patient (this can make the maneuver less awkward)
- Feel for the adman’s apple (laryngeal prominence) with both fingers.
- Move your fingers down and feel for a cartilaginous notch (that is part of the cricoid cartilage)
- Move your fingers below this point and feel for the first pharyngeal cartilage arch. The connection between the sides of the thyroid are below this level. Move your hands right below this first arch (do not push down here because this is very uncomfortable for the patient!).
- Move your hands slightly to the sides of this location (the location of the thyroid lobes) and have the patient swallow while you apply gentle pressure.
Realistically feeling/not feeling the thyroid can both be normal findings. If anything seems suspicious upon palpation (in conjunction with the patient history) further imagine can be informative.
Page Updated: 01.23.2016