2.3 Head and Neck Examination/Findings
Key Takeaways
- Head and neck examination is organized by region—eyes, ears, nose and sinuses, mouth and throat, and neck structures—with inspection, palpation, auscultation, and special tests as appropriate.
- Pupillary, extraocular movement, and visual field findings localize cranial nerve and neurologic pathology that may present as headache or cervical pain.
- Otoscopic and sinus examination findings distinguish uncomplicated URI complaints from mastoiditis, cholesteatoma, and complicated sinus disease.
- Neck examination includes lymph nodes, thyroid, carotid pulses and bruits, jugular venous pressure, and meningeal signs when infection or subarachnoid bleeding is suspected.
- Red flags in the head and neck region—proptosis, unilateral pulsatile tinnitus, hard fixed lymphadenopathy, and painful ophthalmoplegia—require medical referral before chiropractic manipulation.
2.3 Head and Neck Examination/Findings
Clinical Priority: Head and neck content represents roughly 9% of General Diagnosis—eyes, ears, nose and sinuses, mouth and throat, and the neck itself. NBCE vignettes reward systematic regional examination and the ability to connect localized findings to systemic danger.
Examination Sequence and General Approach
Inspect, then palpate, then use special tests and instruments. Compare bilateral symmetry. Note skin, scars, swelling, lesions, and posture (forward head, torticollis). For all headache and cervical cases, perform a brief cranial nerve screen and cervical ROM after ruling out instability.
Eyes
Inspection and Pupils
Observe pupil size, shape, and equality (PERRLA: Pupils Equal, Round, Reactive to Light and Accommodation). Anisocoria may be physiologic if long-standing and <1 mm difference, but new anisocoria with ptosis suggests Horner syndrome (dissection, Pancoast tumor) or third nerve palsy (posterior communicating aneurysm until excluded).
Extraocular Movements (EOMs)
Test H-pattern tracking. Painful EOMs suggest orbital cellulitis, cavernous sinus thrombosis, or thyroid eye disease. Internuclear ophthalmoplegia (impaired adduction with abducting nystagmus) localizes to medial longitudinal fasciculus—multiple sclerosis or brainstem stroke.
Visual Fields and Acuity
Confrontation fields screen CN II pathways. Sudden monocular vision loss suggests retinal artery occlusion or optic neuritis. Papilledema on fundoscopy (when performed) indicates raised intracranial pressure—not a cervicogenic headache pathway.
| Abnormal Eye Finding | Likely Significance | Red-Flag Action |
|---|---|---|
| Painful red eye with cloudy cornea | Acute glaucoma | Same-day ophthalmology |
| Proptosis + chemosis + fever | Orbital cellulitis | Emergency referral |
| New diplopia + headache | Aneurysm, myasthenia, MS | Urgent neuro-imaging/workup |
| Marcus Gunn pupil (APD) | Optic nerve lesion | Neuro-ophthalmology |
| Yellow sclera | Jaundice | Hepatic/biliary evaluation |
Ears
Otoscopic Examination
Use proper speculum size; straighten canal by pulling pinna up and back in adults. Assess tympanic membrane (TM) color, position, landmarks, and perforation.
| Otoscopic Finding | Interpretation | Pitfall |
|---|---|---|
| Bulging red TM | Acute otitis media | Do not manipulate infected ear aggressively |
| Retracted dull TM | Eustachian dysfunction | May refer ear/jaw pain to cervical region |
| Amber fluid level | Middle ear effusion | Common post-URI; hearing may be reduced |
| Perforation with purulent discharge | Chronic suppurative OM | Refer for ENT if cholesteatoma suspected |
| Postauricular erythema/swelling | Mastoiditis | Emergency—intracranial spread risk |
Weber and Rinne tuning fork tests distinguish conductive vs. sensorineural hearing loss when hearing complaint accompanies cervical or TMJ evaluation.
Nose and Sinuses
Inspect external nose for deformity. Anterior rhinoscopy (when available) assesses mucosa, septum, polyps, and discharge. Purulent unilateral discharge suggests foreign body or fungal sinusitis in immunocompromised patients.
Sinus palpation/transillumination (limited sensitivity): maxillary and frontal tenderness with purulent rhinorrhea and fever supports acute bacterial sinusitis. Periorbital swelling and painful EOMs suggest orbital complication—refer urgently.
| Sinus-Related Finding | Benign vs. Dangerous |
|---|---|
| Bilateral congestion post-viral URI | Usually viral rhinosinusitis |
| Unilateral severe pain + high fever + proptosis | Orbital cellulitis/abscess |
| Facial numbness + loose teeth | Maxillary sinus tumor (rare) |
| Black necrotic nasal eschar (immunocompromised) | Invasive fungal sinusitis |
Mouth and Throat
Inspect lips, buccal mucosa, tongue, floor of mouth, palate, tonsils, and dentition. Oral lesions lasting >2 weeks, non-healing ulcers, or leukoplakia require biopsy referral. Trismus may indicate infection (peritonsillar abscess) or TMJ disorder.
Pharyngeal erythema with exudate and cervical lymphadenopathy suggests streptococcal or viral pharyngitis. Uvular deviation suggests CN IX/X palsy or cerebellar stroke. Hot potato voice and drooling suggest epiglottitis or deep space infection—do not provoke gag reflex; emergency airway concern.
TMJ Screening (Chiropractic High-Yield)
Palpate lateral and intra-auricular joint lines, assess opening pattern (deviation, clicking, limited opening), and reproduce pain with loading. Differentiate myofascial pain from intra-articular disc disorder. Red flag: sudden inability to close mouth (luxation) vs. trismus (infection).
Neck Examination
Inspection and ROM
Observe head position, scars, masses, and pulsations. Active and passive cervical ROM with pain mapping; note whether pain is local or radicular. After trauma, apply Canadian C-spine rules concepts before provocative testing.
Palpation
Palpate spinous processes, paraspinal muscles, trapezius, SCM, and suboccipital region. Midline tenderness after trauma raises fracture concern. Step deformity is unstable until cleared.
Lymph Nodes
Systematic chain palpation: submental, submandibular, cervical (anterior/posterior), supraclavicular. Characterize size, mobility, tenderness, and texture.
| Lymph Node Pattern | Likely Etiology | Concern If… |
|---|---|---|
| Tender mobile nodes with URI | Reactive | Resolves in 2–3 weeks |
| Hard fixed supraclavicular node | Malignancy (Virchow) | Always refer for workup |
| Bilateral rubbery nodes | Viral, mono, HIV | Consider mono screen |
| Unilateral progressive painless node | Lymphoma, metastasis | Imaging/biopsy pathway |
Thyroid
Inspect for goiter while swallowing. Palpate isthmus and lobes; note nodules, tenderness, and bruit (Graves disease). Hard fixed nodule with hoarseness suggests malignancy.
Carotid and Jugular
Auscultate carotid bruits in patients with stroke symptoms or cardiovascular risk. Jugular venous distension (JVD) at 45° suggests right heart failure or volume overload—relevant when neck fullness mimics musculoskeletal pain.
Meningeal Signs
When fever and headache coexist, assess neck flexion for rigidity (nuchal rigidity) and consider Kernig and Brudzinski signs—positive findings support meningismus and mandate emergency referral. Do not force painful flexion in trauma until fracture excluded.
Integrative Differential Tables
| Patient Story | Key Exam Maneuver | If Positive, Think… |
|---|---|---|
| Unilateral headache + jaw claudication | Temporal artery palpation (tender, thickened) | Giant cell arteritis |
| Neck pain + fever | TM exam + meningismus | Meningitis, retropharyngeal abscess |
| Ear pain + mastoid tenderness | Postauricular inspection | Mastoiditis |
| Hoarseness + hoarse cough + weight loss | Thyroid and lymph node survey | Thyroid or laryngeal malignancy |
| Facial droop + arm weakness | Cranial nerve and motor screen | Stroke—time-critical |
Examination Pitfalls
| Pitfall | Risk | Correction |
|---|---|---|
| Attributing all headache to C1–2 without neuro screen | Miss aneurysm, GCA, IIH | Complete eye and neuro red-flag screen |
| Aggressive ROM in acute trauma | Cord injury | Clear with rules/imaging first |
| Ignoring unilateral hearing loss | Acoustic neuroma, cholesteatoma | Audiometry/ENT referral |
| Palpating only painful SCM in "neck pain" | Miss lymphoma, thyroid cancer | Examine nodes and thyroid routinely |
| Otoscopy without pain control in child | Incomplete exam | Defer or refer if unable to visualize TM |
NBCE head-and-neck items often show a normal cervical ROM with one abnormal eye or ear finding—the correct answer refers or orders the appropriate specialty workup, not cervical manipulation.
A 72-year-old reports new temporal headache and jaw pain when chewing. Temporal artery palpation reveals tender, thickened vessels. Visual acuity is slightly reduced. What is the most appropriate management?
Otoscopic examination shows a bulging, erythematous tympanic membrane with loss of light reflex in a febrile child. What finding would most increase concern for intracranial complication?
Which lymph node location is most concerning for underlying malignancy when a firm, non-tender, fixed node is palpated?
A patient with severe sore throat has muffled "hot potato" voice, drooling, and stridor. What is the priority action?