Primary Care Otolaryngology

Chapter 2

The Salivary Glands The parotid and submandibular glands should be inspected and palpated to detect enlargement, masses, and/or tenderness. The Neck The normal neck is supple, with the laryngotracheal apparatus easily pal- pable in the midline. A complete examination should include external observation for symmetry and thorough palpation of all tissue for possible masses. The exact position, size, and character of any mass should be care- fully noted, along with its relationship to other structures in the neck (thy- roid, great vessels, airway, etc.). Cranial Nerves A complete head and neck exam includes testing of cranial nerves (CN) II–XII. A pocket eye chart should be used to test the patient’s vision ( Optic - CN II ). Extraocular eye movements should be tested, along with the pupillary response to light ( oculomotor, trochlear, and abducens— CN III, IV, and VI , respectively). The trigeminal nerve (CN V) can be tested by testing areas of the face using a pin and a wisp of cotton. Having the patient clench his teeth and then open his jaw against resistance also tests CN V. Test the facial nerve (CN VII) by having the patient raise his eyebrows, squeeze his eyes shut, scrunch his nose, pucker his lips, and smile. The vestibulocochlear nerve (CN VIII) can be tested with a tuning fork. CN IX (glossopharyngeal) and CN X (vagus) control swallowing, the gag reflex, and speech, and so are tested by observing these actions. Have the patient swallow and say “ah, ah, ah.” You can also touch the back of the throat with a tongue depressor to check the gag reflex. Assessment of vocal cord function by flexible fiberoptic laryngoscopy also provides information on the status of the vagus nerve. Assess the function of the spinal accessory nerve (CN XI) by asking the patient to push his head laterally against resistance and shrug his shoulders against resistance. Finally, assess the hypoglossal nerve (CN XII) by having the patient stick out his tongue. Deviation to one side indicates a weakness or paralysis of the nerve on that side. Differential Diagnosis Every time you see a new patient, you begin to formulate a differential diagnosis for him or her. Most of us begin by doing this randomly, usually the five most recent diagnoses we have seen for this set of symptoms and physical findings . This works when you have seen several thousand patients, but it is not as useful if you have seen only 100 or so. A useful

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Primary Care Otolaryngology