Assessing the Throat (Mouth and Pharynx)

• Inspect:
  • Lips for color, moisture, masses, cracks, sores, fissures, and symmetry.
  • Oral mucosa for color, lesions, dryness/moisture, masses, and swelling.
  • Tongue for color, thickness, moisture, symmetry of movement left and right, and deviations from midline (cranial nerve XII). Palpate the tongue and floor of the mouth for masses and swelling.
  • Teeth for their general condition and evaluate if any are missing.
  • Gums for color, texture, swelling, retraction, and bleeding.
  • Uvula for movement, position, size, symmetry, and color.
  • Pharynx (hard and soft palate) for color, redness, inflammation, exudate, masses, and lesions.
  • Tonsils for size, color, inflammation, and exudate.
  • Salivary glands (parotid, sublingual, and submaxillary) for patency and signs of inflammation or redness.
• Check the patient’s ability to swallow and their gag reflex (cranial nerves IX and X).
  • The thyroid is typically not visible. Assess for an enlarged thyroid gland at the suprasternal notch.

Assessing the Neck

• Check neck muscles for symmetry, masses, swelling, and range of motion.
• Palpate cervical lymph nodes for signs of swelling or tenderness; cervical lymph nodes should not be fixed (unmovable) or palpable (unless the patient is very thin). Lymph nodes should be small and freely moving.
• Assess head and neck range of motion.
• Check trapezius muscle strength. Ask the patient to shrug their shoulders against your hands as you apply resistance (cranial nerve XI).
• Check cervical muscle strength. Ask the patient to turn their chin/jaw against your hand.
• Assess trachea for deviation; it should be midline.
• Evaluate thyroid gland noting enlargement or presence of nodules and masses; it should be smooth.
• Examine the carotid arteries as part of the cardiac assessment, taking care to palpate the carotid arteries one at a time, noting symmetry, strength, amplitude, and presence of an abnormal thrill. Listen for bruits using the diaphragm of your stethoscope.
• Assess for cervical point tenderness along the posterior aspect of the neck.

PEARLS

• Compare any new findings with the patient’s past medical history.
• Due to sun exposure, skin cancers can develop on the scalp, and in fact the scalp accounts for up to 49% of melanomas.
• The elements of the HEENT assessment can be interwoven with the cranial nerve assessment.
• Ptosis may be congenital or caused by a disorder affecting the muscle tendon, muscle, or nerve of the eyelid. Unilateral ptosis with impaired extraocular movement suggests a compressive third cranial nerve palsy.
• A yellowish discoloration of the sclera indicates jaundice.
• Signs of Cushing’s syndrome on the face include moon facies (a rounded face), hirsutism (male pattern hair growth on the face), and acne (papular or pustular lesions).
• Pain with movement of the auricle and tragus of the ear occurs in acute otitis externa (inflammation of the ear canal), but not in otitis media (inflammation of the middle ear).
• In viral rhinitis, the nasal mucosa is often red and swollen; in allergic rhinitis, it may be pale, bluish, or red.
• Tracheal deviation could be a serious sign of tension pneumothorax, pleural effusion, tumor, or goiter.