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Clinical Practicum II / Week Four Objectives:
By: Alberto Caban Jr, Class of 2008
Head, Neck and Oral Exam: Chapter 8 (pp 179-193) and
Chapter 11 (pp 285-314) (Swartz)
Chapter Eight:
State the contents of the anterior triangle of the neck.
o The anterior triangle contains: thyroid gland, larynx, pharynx, lymph nodes, submandibular salivary gland, and fat.
o Boundaries: anterior border of SCM muscle, the clavicle inferiorly, and the midline of
the neck anterior.
Anterior Triangle of the Neck
Name and show the location of the ten lymph node chains of the head and neck,
supraclavicular, and infraclavicular areas.
Preauricular:
Node
Postauricular:
Tonsillar:
Submaxillary (a.k.a. submandibular):
Submental:
Occipital:
Anterior cervical:
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Location / Drainage
in front of tragus; drains face, auditory canal,
conjunctiva.
behind ear, above mastoid process; drains scalp
and auditory canal.
at angle of jaw; drains face and oral cavity.
below & in front of angle of mandible & drains
lower teeth
under chin; drains lower face, floor of mouth.
base of skull; drains posterior scalp.
at angle of jaw with a chain along anterior border
of SCM to clavicle; drains scalp, face, tonsils,
pharynx.
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Node (Con’t)
Posterior cervical:
Supraclavicular:
Infraclavicular:
Location / Drainage (Con’t)
located beneath the posterior margin of SCM
with a chain going down to posterior base of
neck; drains posterior scalp, ear, skin of posterior
neck.
lies deep and behind the clavicles; drains thorax
abdomen, arm, breast, cervical chains. (Must
have patient. inhale to properly palpate)
lies inferior to clavicles on anterior chest, drains
axillae.
Lymph nodes of the neck and their drainage
Demonstrate the correct palpation technique for all head and neck lymph node chains.
o When you palpate the neck lymph node chains look for tenderness, mobility, consistency,
size and symmetry. Use the table above to find the proper location for each node.
Properly perform palpation of the thyroid gland by both anterior and posterior
approaches.
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o Anterior approach: The examiner stands in front of and facing the patient and flexes the
patient’s neck slightly forward to relax the SCM muscle. The examiner then uses the
fingers of his left hand to displace the trachea slightly to the patient’s left. The examiner
then checks the consistency and configuration of the left thyroid lobe with and without
swallowing. To do this, he/she palpates the full length of the left lobe using the fingertips
of his/her right hand and palpating in a posteriomedial direction. The hands are reversed
and this technique repeated for examining the right lobe.
o Posterior approach: The examiner stands behind the seated patient, placing his hands
around the patient’s neck. Depending on patient’s neck size and examiner’s preference,
the examiner may chose to slightly extend or flex the patient’s neck. The examiner
correctly positions his/her fingers and systematically palpates both thyroid lobes with and
without swallowing. Each time the patient swallows; the examiner pushes the trachea to
one side with the fingers of one hand and rolls the fingertips of the other hand over the
full extent of the thyroid gland palpating in a posteriomedial direction. (done for both
lobes).
Define the importance of palpation of the thyroid gland for consistency and size.
o When palpating the thyroid gland, please look for size, symmetry, consistency,
tenderness, nodules and mobility. The thyroid should be similar in consistency to muscle
tissue. The left thyroid lobe is typically slightly larger than the right lobe. Use the
swallowing tests for thyroid size and the adherence of the thyroid to surrounding tissues.
If the thyroid gland is enlarged, auscultate over the lateral lobes with a stethoscope to
detect a bruit. This can sometimes be heard with hyperthyroidism.
State the symptoms and physical exam findings associated with hyperthyroidism and
hypothyroidism.
o An enlarged thyroid may be associated with hyperthyroidism, hypothyroidism, or a
simple or multinodular goiter of normal function.
Symptoms of HYPERthyroidism
Organ System
Symptom
General
Preference for
the cold
Weight loss
with good
appetite
Eyes
Neck
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Prominence of
eyeballs
Puffiness of
eyelids
Double vision
Decreased
motility
Goiter
Symptoms of HYPOthyroidism
Organ System
Symptom
Sign
General
Weight gain
Obesity
with regular
diet
Chilly while
others are
warm
GI
Constipation
Enlarged tongue
Cardiovascular
Fatigue
Hypotension
Bradycardia
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Symptoms of HYPERthyroidism
Organ System
Symptom
Cardiac
Palpations
Peripheral
edema
GI
Increased
bowel
movements
Genitourinary
Polyuria
Decreased
fertility
Neuromuscular
Fatigue
Weakness
Tremulousness
Nervousness
Irritability
Hair thinning
Increased
perspiration
Change in skin
texture
Change in
pigmentation
Emotional
Dermatologic
Symptoms of HYPOthyroidism
Organ System
Symptom
Sign
Nervous
Speech
Hyporeflexia
Disorders
Defective abstract
Short
reasoning
attention
Spasticity
span
Tremor
Tremor
Depressed affect
Musculoskeletal
Lethargy
Hypotonia
Thickened,
Puffy facies
dry skin
Hair loss
Brittle nails
Leg cramps
Puffy
eyelids
Puffy
cheeks
Reproductive
Heavier
Menses
Decreased
fertility
Define relevant symptoms for the diagnosis of head or neck disorders.
o The most common symptoms related to the neck are:
Neck Mass
Neck stiffness
Define medical terminology and vocabulary roots in this chapter.
Capit
Cephal(o)Cleido-
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Head
Head
Clavicle
Capitate
Cephalometry
Cleidomastoid
Head-shaped
Measurement of the head
Pertaining to the clavicle and mastoid
process
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CranioOccipitoOdont(o)Thyro-
Skull
Back portion of the
skull
Tooth; teeth
Thyroid gland
Craniomalacia Abnormal softening of the skull
Occipitoparietal Pertaining to the occipital and parietal
bones
Odontorrhagia Hemorrhage following tooth extraction
Thyromegaly Enlargment of the thyroid gland
Chapter Eleven:
Properly perform inspection of the buccal mucosa, gingivae, teeth, tongue, tonsils, palate,
salivary glands and uvula of the oral cavity.
o Step 1: MUST look at the patient’s wide-opened mouth with a light.
o Buccal mucosal for any lesions, color changes or white patches, injection, swelling,
papules, ulcers, erosions, painful areas, and hemorrhages (petechiae).
o Condition of teeth and gums check for state of dentition, receding gums, malformation
or discoloration of teeth, caries, hygiene.
o Tongue can be described as geographic or smooth, if there are any lesions, color
changes, ulcers, masses etc. Tongue should be pale pink, glistening and without growths
or lesions.
o Uvula is located midline, same color as palate and aids in closing off nasopharynx and
with swallowing.
o Hard palate (anterior) and soft palate (posterior)- look for ulceration, masses, white
plaques, swelling.
o Stenson’s Ducts visualize the area of the opening opposite the 2nd upper molars.
o Floor of mouth patient is asked to elevate his tongue to the roof of his mouth so that
examiner can visualize any mucosal lesions.
Describe the locations of Stensen’s and Wharton’s ducts and state the purpose of each.
o Opening of Stenson’s ducts: opposite the 2nd upper molars (parotid gland duct); The
ducts from the parotid glands (the salivary glands located in the cheek around the angle
of the jaw) exit from the cheeks.
o Wharton’s ducts located on either side of the frenulum at the base of the tongue
(drainage from submandibular salivary gland duct).
Define relevant symptoms in the diagnosis of oral cavity disorders.
o Pain
o Ulceration
o Bleeding
o Mass
o Halitosis (bad breath)
o Xerostomia (dry mouth)
Define the following terms: dysphagia ,dysphonia, xerostomia, ptyalism and deglutition.
o Dysphagia: difficulting is swallowing
o Dysphonia: change in voice, customary with laryngeal disease
o Xerostomia: dry mouth due to reduced or absent salivary secretion
o Ptyalism: excessive production of saliva
o Deglutition: The act of swallowing, particularly the swallowing of food.
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Properly perform palpation of the tongue and floor of mouth.
o Tongue: Patient is asked to stick his/her tongue out onto a piece of unfolded gauze that is
then wrapped around it. The tongue is palpated with the fingers of the free hand with
special attention given to the lateral sides (palpate the full length). Lateral margins are
palpated carefully because 85% of lingual cancers are found in this area. Describe any
palpable lesions or induration. FYI: The anterior 2/3 of tongue is innervated by facial
nerve and the posterior 1/3 by the glossopharyngeal nerve. The tip of the tongue tastes
sweet, the posterior 1/3 tastes sour or bitter and the lateral tongue tastes salt.
o Floor of mouth: Patient is asked to elevate his tongue to the roof of his mouth. The
examiner then palpates the floor of the mouth and the opening of Wharton’s ducts located
on either side of the frenulum at the base of the tongue (submandibular salivary gland
duct). This is done by placing a gloved finger under the tongue and palpating the entire
floor of the mouth for lesions, masses, tenderness, swelling etc.
Assess function of Cranial Nerves IX, X, and XII by testing the gag reflex, tongue
protrusion and vocalization of the sound “ah”.
o Observes uvula as patient says”ah” (CN IX, X): Symmetrical elevation of the soft palate
with the portion of the uvula attached to the soft palate remaining midline as the patient
says “ah” demonstrates normal coordinating function of CN’s IX and X.
o Tests gag reflex (CN IX, X)- Symmetrical elevation of the soft palate seen with a gag
indicates intact CN’s IX and X.
o Evaluates tongue protrusion (CN XII): Observe for fasciculations while the tongue rests
on the floor of the mouth. Observe the position of the tongue as the patient is asked to
“stick out your tongue”. Protrusion in the midline indicates intact hypoglossal nerves (CN
XII).
State the normal and abnormal findings for each nerve tested.
o Refer to objective above.
Summarize typical examination features and risk factors for oral cavity carcinomas.
o Carcinoma of the lip accounts for 30% of all cancers in this area and approximately 0.6%
of all cancers. Most of these malignant tumors are squamous cell carcinomas. The lower
lip is the site most frequently involved (95%). The patients are usually 50-70 years of
age, with a strong male predominance (95%). Squamous cell carcinoma is characterized
by a hard, infiltrative, usually painless ulcer.
o The risk factors that predispose to squamous cell carcinoma of the oral cavity are the
same as for leukoplakia:
Smoking
Spirits (alcohol)
Spices
“5 S’s”
Syphilis
Spikes (ill-fitting dentures)
Define medical terminology and vocabulary roots discussed in this chapter.
ArytenoidsBucco-
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Pitcher-shaped
Cheek
Arytenoiditis
Inflammation of the arytenoid cartilage
Buccopharyngeal Pertaining to the check and pharynx
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Cheil(o)DentGingivGloss(o)-labiLeuko-
Lip
Tooth
Gingiva(e)
Tongue
Lips
White
Cheilitis
Dental
Gingivectomy
Glossoplegia
Nasolabial
Leukoplakia
Linguo-plakia
Tongue
Patch
Linguopapillitis
Erthroplakia
PtyalStoma-
Saliva
Mouth;
opening
Ptyalism
stomatitis
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Inflammation of the lip
Pertaining to the teeth
Surgical excision of diseased gingival(e)
Paralysis of the tongue
Pertaining to the nose and lip
White patch on mucous membrane;
oftenpremalignant
Painful ulcers around the papillae of the tongue
Red patch of mucous membrane; often
premalignant
Excessive salivation
Inflammation of the mouth
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