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X THE EAR, NOSE, MOUTH,AND THROATHORACE GREEN OF VERMONT

T h e f i r s t A m e r i c a n p h y s i c i a n t o s p e c i a l i z e

i n d i s e a s e s o f t h e t h r o a t w a s H o r a c e G r e e n ,

w h o s e c l a s s i c b o o k , A T r e a t i s e o n D i s e a s e s o f

t h e A i r P a s s a g e s , w a s p u b l i sh e d i n 1 8 4 6 . B o r n

i n 1 8 0 2 i n C h i t t e n d e n , V e r m o n t , G r e e n w a s

the son of a Revolutionary War veteran

w h o s e t h r e e b r o t h e r s d i e d i n t h a t w a r . G r e e n

g r a d u a t e d f r o m C a s t l e t o n M e d i c a l C o l l e g e

i n V e r m o n t i n 1 8 2 4 a n d u n d e r t o o k a n a p -

p r e n t i c e s h i p w i t h h i s b r o t h e r i n R u t l a n d ,

V e r m o n t , f o r 6 y e a r s . I n 1 8 3 0 h e a t t e n d e d

t w o c o u r s e s o f m e d i c a l l e c t u r e s a t t h e U n i -

v e r s i t y o f P e n n s y l v a n i a a n d t h e n r e t u r n e d

t o g e n e r a l p r a c t i c e i n V e r m o n t .

I n 1 8 3 8 , a t a g e 3 6 , G r e e n w e n t t o E u r o p e

f o r 5 m o n t h s t o a t t e n d l e c t u r e s a n d c l i n i c s .

In London he engaged in a conversation

w i t h J a m e s J o h n s o n , e d i t o r o f t h e B r i t i s h a n d

F o r e i g n M e d i c a l R e v i e w , w h o i n s p i r e d G r e e n

b y r e m a r k i n g t h a t a l l m o d e s o f t r e a t i n g l a r -

y n g e a l d i s e a s e w o u l d f a i l u n t i l p r o p e r a g e n t s c o u l d b e a p p l i e d d i r e c t l y t o t h e

m e m b r a n o u s l i n i n g o f t h e l a r y n x . O n h is r e tu r n in 1 8 3 8 to t h e U n i te d S t at e s ,

G r e e n t o o k r e s i d e n c e i n N e w Y o r k C i t y a n d b e g a n 1 8 e x c i t i n g y e a r s i n l a r y n -

g o l o g y , p u b l i s h i n g h i s t r e a t i s e i n 1 8 4 6 a t a g e 4 3 . H e w a s p r o f e s s o r i n C a s t l e t o n

M e d i c a l C o l l e g e f r o m 1 8 4 0 t o 1 8 4 3 a n d p r o f e s s o r i n N e w Y o r k M e d i c a l C o l l e g e

f r o m 1 8 5 0 , u n t i l h i s r e s i g n a t i o n i n 1 8 6 0 a t a g e 5 9 . H e w a s t h e a u t h o r o f t h r e e

b o o k s a n d n u m e r o u s a r t i c l e s a n d h e l p e d f o u n d t h e American Medical Monthly i n

1854 .

G r e e n w a s t h e f i r s t p h y s i c i a n t o a p p l y t o p i c a l m e d i c a t i o n t o t h e l a r y n x u s i n g

a p r o b a n g , a n d h i s c l a i m i n 1 8 4 6 c a u s e d a n i n t e r n a t i o n a l c o n t r o v e r s y . H i s m e t h o d

w a s t o s o a k s i l v e r n i t r a t e i n a s p o n g e a t t a c h e d t o t h e t i p o f a 1 0 - i n c h , c u r v e d

w h a l e b o n e , a n d a p p l y t h e s p o n g e d i r e c t l y t o t h e l a r y n x . B e c a u s e s o f e w p h y -

s i c i a n s b e l i e v e d t h a t t h e l a r y n x c o u l d t o l e r a t e t h e p r e s e n c e o f a f o r e i g n b o d y ,

G r e e n w a s a c c u s e d o f f r a u d . H e s u f fe r e d d i sr e p u t e f o r a de c a d e u nt i l he d e m -

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o n s t r a t e d h i s t e c h n i q u e o n pa t i e n t s i n 1 8 5 5 b e f o r e a c o m m i t t e e a p po i n t e d b y

the New York Academy of Medicine . In a private au tobiography, he described

t h e c i r c u m s t a n c e s :

A f t e r m y r e t u r n f r o m m y s e c o n d t r i p t o E u r o p e i n 1 8 5 1 , 1 e n t e r e d w i t h m o r e s p i r i t

t h a n e v e r i n t o t h e p r a c t i c e of m y " s p e c i a l t y , " t h e e m p l o y m e n t of l o c a l t r e a t m e n t o f t h e

a i r p a s s a g e s . M y p r a c t i c e h a d g r e a t l y i n c r e a s e d . M y p a t i e n t s c a m e f r o m a l l p a r t s of t h e

w o r l d , b u t w i t h t h i s c a m e a l s o a n i n c r e a s e of o p p o s i t i o n f r o m m y p r o f e s s i o n a l b r e t h r e n .

Those who were unfortu nate in business or from some other cause were envious of mys u c c e s s . T h e y e v i n c e d a v e r y u n k i n d s p i r i t a n d d e n i e d t h e p o s s i b i l i t y of my doing what

I w a s d o i n g i n m y o f f i c e e v e r y d a y . B u t I w o u l d n o t q u a rr e l w i t h t h e m , t ru s t i n g t h a t

the truth would ultimately be known, and my word vindicated . F o r s e v e r a l y e a r s n o w

I have heard nothing of t h i s o p p o s i t i o n . (Green, 1865)

T h e f o l l o w i n g p a s s a g e f r o m l e t t e r s b y a p a t i e n t , J u l i a R o b e r t s o n P i e r po n t ,

w h o u n d e r w e n t a t h r o a t o p e r a t i o n , v i v i d l y d e s c r i be s t h e a p pe a r a n c e , m a n n e r ,

a n d p r a c t i c e o f G r e e n a t h i s h o m e i n V e r m o n t i n 1 8 5 0 :

Everything was done to make me comfortable and at home . T h e h o u s e i s v e r y l a r g e

a n d f u r n i s h e d e l e g a n t l y - c o s t l y p a i n t i n g s a n d s t a t u a r y a r e s c a t t e r e d o v e r t h e b u i l d i n g .

I t i s l i g h t e d b y g a s , a n d t h e C r o t o n w a t e r , h o t a n d c o l d , i s c a r r i e d a l l o v e r i t . T h e r e

a r e s p e a k i n g t r u m p e t s i n t h e w a l l s , i n f a c t e v e r y t h i n g e l e g a n c e o r c o m f o r t c o u l d s u g g e s t .

Dr. keeps his carriage and I don't know how many serv ants . W e d i n e b y c a n d l e l i g h tand have lunch at one o'clock . The dinner is a very ceremonious affair, and I get

a l m o s t t i r e d o u t b e f o r e i t i s o v e r . B u t I l e a r n a g r e a t d e a l a t t h e t a b l e , f o r t h e c o n v e r s a t i o n

i s q u i t e r e f i n e d a n d i n t e l l e c t u a l . Dr . G r e e n i s a b o u t f o r t y , y o u n g l o o k i n g , h a n d s o m e ,

p o l i t e , b u t s o m e t i m e s a b s e n t m i n d e d , h a s t r a v e l e d i n E u r o p e a n d l i k e s s ty l e b u t n o t

d a s h i n g . Dr. J e n k i n s i s D r . G ' s j u n i o r p a r t n e r i s t a l e n t e d , a m i a b l e , k i n d , p o l i t e , w i t t y ,and a great t a l k e r , b u t a l w a y s t a l k s t o t h e point .

L a s t n o t l e a s t I w i l l t e l l y o u a b o u t m y t h r o a t - D r . G r e e n s e n t f o r m e t o g o t o t h e

o f f i c e a f e w d a y s a f t e r I c a m e a n d l o o k e d a t m y t h r o a t . " B a d e n o u g h , " w a s h i s e x c l a -

mation . " T h e r e i s a d e e p u l c e r a t i o n o u t o f s i g h t , y o u r p h y s i c i a n s h a v e n o t d i s c o v e r e d

i t ." Said he, "What would you say Miss R . i f I s h o u l d b e o b l i g e d t o c u t a w a y s o m e of

t h a t b a d f l e s h t h a t i s i n y o u r w a y t h e r e ? " I r e p l i e d , " W h a t e v e r y o u t h i n k b e s t t o d o I

w i l l e n d e a v o r t o s u b m i t t o p a t i e n t l y " - " W e l l t h e n t h e s o o n e r i t i s o v e r t h e b e t t e r , d o

y o u n o t s a y s o ? " I a n s w e r e d , " Y e s b y a l l m e a n s " - I s e a t e d m y s e l f a n d w h i l e h e p r e p a r e d

h i s i n s t r u m e n t s , h e s a i d i t w o u l d s o o n b e o v e r a n d s p o k e l o w a n d s w e e t l y t o m e , b u t h e

w a s m i s t a k e n i n h i s l a d y , I n e e d e d n o c o a x i n g a n d h a d d e t e r m i n e d b e f o r e h a n d t o m a k e

n o f u s s , i f i t k i l l e d m e - s o I s m i l e d a n d s a i d n o t h i n g . Dr. Jenkins came behind me, I

a f t e r w a r d l e a r n e d , t o h o l d m y h a n d , b u t t h a t w a s u n n e c e s s a r y a n d h e d i d n o t t o u c h i t .

I s a t p e r f e c t l y s t i l l , a n d t h e D r . c u t o f f m y l e f t t o n s i l . The blood streamed from my mouth

for about half an hour, and then I sat down and had the right one cut off-after it

s t o p p e d a l i t t l e , a s p o n g e a p p l i c a t i o n o f n i t r a t e of s i l v e r w a s a p p l i e d a n d a l m o s t s t r a n g l e d

me . The bleeding began again and continue d until two o'clock-an d for a few days I

s u f f e r e d a g r e a t d e a l of pain, but I had kind nursi ng and "French fixins" t o g e t w e l l

on . ( P i e r p o n t , 1 8 5 0 )

A laryngoscope was first us ed by Garcia in Europe in 1855, but Green was

largely responsible for advancing its use in the United States . In 1858 he obtained

one from Vienna through a New York surgeon, and in the company of his

partner, John H . D o u g l a s , l a t e r p h y s i c i a n t o U . S . G r a n t , G r e e n b e g a n t o u s e

t h e i n s t r u m e n t i n h i s p r a c t i c e . A f t e r h i s r e t i r e m e n t i n 1 8 60 , G r e e n w a s d e e p l y

affected by the C ivil War, for " it was a great trial to him to be unable to do as

h i s f o r e f a t h e r s h a d d o n e - b e a r a r m s i n h i s c o u n t r y ' s d e f e n s e ; and he ha d no

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s o n s o l d e n o u g h t o s e n d t o t h e w a r " ( F r a n c i s , 1 8 6 7 ) . A y e a r a f t e r t h at w a r e n de d ,

h e d i e d o f t u b e r c u l o s i s a t a g e 6 6 .

-CHARLES STEWART ROBERTS

REFERENCESFrancis SW . H o r a c e G r e e n , M . D . , L . L . D . , e t c . Med Surg Reporter 1867 ; 1 6 :64-66 .G r e e n H . A u t o b i o g r a p h y . MSS, New York Academy of Medicine, New Yor k, 1865 .

Pierpont JR . L e t t e r s . MSS, New York Academy of Medicine, New York, 1850 .

Synder C . T h e i n v e s t i g a t i o n o f H o r a c e G r e e n . L a r y n g o s c o p e . 1 9 7 5 ; 8 5 :2012-22 .

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1 1 9A n Ov e r v i e w o f t h eHead and NeckJOHN S. T U R N E R , J R .

E v a l u a t i o n o f t h e h e a d a n d n e c k a r e a i n v o l v e s c l o s e a t t e n -

t i o n t o d e t a i l s o f h i s t o r y a n d s y m p t o m s , i n t r i c a t e p h y s i c a l

e x a m i n a t i o n , a n d p r o p e r u s e o f s p e c i a l t y e q u i p m e n t .

Histor y

B e g i n b y a s k i n g a b o u t t h e n o s e a n d p a r a n a s a l s i n u s e s . The

e x a m i n e r s h o u l d i n q u i r e a b o u t t h e p r e s e n c e a n d d u r a t i o n

o f t r a u m a , n o s e b l e e d s ( C h a p t e r 1 2 4 ) , d r a i n a g e , f a c i a l a c h -

i n g , c o n g e s t i o n , o r p r e v i o u s s u r g e r y . T h e t y p e a n d s e v e r i t y

o f t r a u m a , a d e s c r i p t i o n o f t h e t y p e o f d r a i n a g e , a n d t h e

d e g r e e o f p a i n o r s w e l l i n g s h o u l d b e c a r e f u l l y n o t e d . A s -

s o c i a t e d c o n g e s t i o n i n t h e n o s e a n d r e c o r d s o f a l l p r e v i o u s

n a s a l o r h e a d a n d n e c k s u r g e r y s h o u l d b e r e c o r d e d . F r e -

q u e n t o c c u r r e n c e o f c o l d s , h a y f e v e r r e a c t i o n s , a n d s e a s o n a l

e x a c e r b a t i o n o f t h e s e p r o b l e m s s h o u l d b e r e c o r d e d . S n o r -

i n g , t h e u s e o f i n t r a n a s a l d r u g s s u c h a s c o c a i n e o r c r a c k , o r

p r o l o n g e d u s e o f n a s a l s p r a y s a n d t h e i n t a k e o f o t h e r d e -

congestant medicati ons should be documented . F r e q u e n t

r e d n e s s o r s w e l l i n g o f t h e e y e s s h o u l d b e n o t e d a l s o .

N e x t c o n s i d e r t h e o r a l c a v i t y a n d s a l i v a r y g l a n d s . The ex-

a m i n e r s h o u l d i n q u i r e a b o u t t h e p r e s e n c e a n d d u r a t i o n o f

t h e f o l l o w i n g l e s i o n s i n a n d a b o u t t h e m o u t h a n d l i p s : u l c e r s

o r c a n k e r s o r e s , t e n d e r g u m s o r p a i n f u l t e e t h , x e r o s t o m i a

( d r y m o u t h ) , f i s s u r e s a t t h e c o r n e r o f t h e m o u t h o r t h e

t o n g u e , a n d t h e p r e se n c e o f b l o o d i n s a l i va . T h e p a t i e n t

s h o u l d b e a s k e d a b o u t t o n g u e s o r e n e s s , r e c e n t d e n t a l w o r k ,

d i f f i c u l t y c h e w i n g , e x c e s s s a l i v a o r t h i c k s a l i v a , t h e c h r o n i c

u s e o f t o b a c c o , a n d u n u s u a l h a b i t s s u c h a s b r u x i s m o r n o c -

t u r n a l g r i n d i n g o f t h e t e e t h . T h e p a t i e n t s h o u l d b e a s k e d

a b o u t t h e p o s s i b i l i t y o f p r e v i o u s s w e l l i n g o r t e n d e r n e s s u n -

d e r t h e j a w , i n t h e p r e a u r i c u l a r a r e a , i n t h e p a l a t e o r o n

t h e t o n g u e , o r a n y l i m i t e d o r p a i n f u l j a w m o t i o n s .

F o r t he j a w a n d t e m p o r o m a n d i b u l a r j o i n t s , a h i s t o r y s h o u l d

be taken to document the presence and duration of the

f o l l o w i n g : t r a u m a , b r a c e s o r o r t h o d o n t i c t r e a t m e n t , c l i c k i n g

o r c r u n c h i n g s o u n d s w h e n o p e n i n g t h e m o u t h , p r e a u r i c u l a r

s w e l l i n g , t e n d e r n e s s t o p a l p a t i o n , t e e t h g r i n d i n g a t n i g h t ,

f r e q u e n t c l e n c h i n g o f t e e t h d u r i n g t h e d a y , o r p a i n o r d i s -

c o m f o r t i n t o t h e t e m p l e o r d o w n t h e s i d e o f t h e n e c k . T h e

p a t i e n t s h o u l d a l s o b e a s k e d a b o u t r i n g i n g i n t h e e a r o r

t i n n i t u s , a s s o c i a t e d s e n s a t i o n s o f d i z z i n e s s o r u n s t e a d i n e s s ,

a n d t h e p re s e n c e o f e a r f u ll n e s s . T h e u s e o f d e n t u r e s o r

b r i d g e s s h o u l d b e d o c u m e n t e d , a n d t h e p a t i e n t ' s h i s t o r y

c o n c e r n i n g e x c i s i o n o f t h i r d m o l a r s ( w i s d o m t e e t h ) o r o t h e r

e x t r a c t i o n s s h o u l d b e d o c u m e n t e d .

F o r t h e p h a r y n x , l a r y n x , a n d t h y r o i d g l a n d , the examiner

s h o u l d i n q u i r e a b o u t t h e p r e s e n c e a n d d u r a t i o n o f s o r e

t h r o a t s a n d p r e v i o u s a n t i b i o t i c t r e a t m e n t f o r p h a r y n g i t i s o r

mouth ulcers . Q u e s t i o n s s h o u l d b e a s k e d a b o u t d i f f i c u l t y

s w a l l o w i n g , t h e p r e s e n c e o f g l a n d o r n o d e e n l a r g e m e n t i n

589

t h e n e c k , t h e p r e s e n c e o f h o a r s e n e s s ( C h a p t e r 1 2 5 ) , o r t h e

p r e s e n c e o f b l o o d i n t h e s p u t u m ( h em o p t y s i s ) . O c c u p a t i o n a l

e x p o s u r e s t o c h e m i c a l s , d u s t , o r v a r i o u s g a s e s s h o u l d b e

d o c u m e n t e d . A n y k n o w n r e s p i r a t o r y a l l e r g e n s s h o u l d b e

recorded. Tobacco use should be documented, and the

number of years of usage recorded . U n u s u a l u s e o f t h e

v o i c e , s u c h a s p r o f e s s i o n a l s i n g i n g o r t a l k i n g c o n s i s t e n t l y

a b o v e a n o i s y e n v ir o n m e n t , s h o u l d b e no t e d . T h e p r e s e n c e

o f a n i r r i t a t i v e c o u g h , t e n d e r n e s s o r f u l l n e s s u n d e r t h e c o l -

l a r , o r c o n s i s t e n t c l e a r i n g o f t h e t h r o a t s h o u l d b e d o c u -

m e n t e d . T h e p a t i e n t s h o u l d b e a s k e d a b o u t p a i n o n n e c k

motion . T h e r e g u l a r u s e o f a n y p r e s c r i p t i o n d r u g s s h o u l d

be recorded . B e c a u s e a l m o s t o n e - t h i r d o f A I D S p a t i e n t s

p r e s e n t w i t h h e a d a n d n e c k d i s o r d e r s , a n y h i s t o r y o f r i s k

f a c t o r s f o r t h e d i s e a s e s h o u l d b e i n v e s t i g a t e d ( h i g h - r i s k s e x -

u a l p r a c t i c e s , u s e o f i n t r a v e n o u s d r u g s w i t h s h a r e d n e e d l e s ,

b l o o d t r a n s f u s i o n s ) .

I n c o l l e c t i n g i n f o r m a t i o n a b o u t p r o b l e m s i n v o l v i n g t h e

f a c e , t h e p a t i e n t s h o u l d b e a s k e d a b o u t d i s c o m f o r t i n t h e

c h e e k o r f o r e h e a d , u n u s u a l p a i n s f o l l o w i n g d e n t a l p r o c e -

d u r e s , o r u nu s u a l s e n s i t i v i t y t o s u n l i g h t . I n q u i r i e s s h o u l d

b e m a d e a b o u t p r o l o n g e d o c c u p a t i o n a l e x p o s u r e s t o s u n -

l i g h t , c h e m i c a l s , o r d u s t . P a t i e n t s s h o u l d b e a s k e d i f t h e y

h a v e u s e d p r o t e c t i v e h a t s o r m a s k s w h e n a r o u n d t h e s e s u b -

s t a n c e s . Q u e s t i o n s a b o u t t h e s e v e r i t y o f a c n e i n a d o l e s c e n c e

o r r e c u r r e n t s k i n i n f e c t i o n s s h o u l d b e n o t e d . T h e p a t i e n t

s h o u l d b e a s k e d a b o u t v i s u a l d i s t u r b a n c e s r e l a t e d t o s a g g i n g

e y e l i d o r t h e p r e s e n c e o f a n y d o u b l e v i s i o n , w h i c h i n d i c a t e s

o b s t r u c t i o n o f v i s i o n .

F o r e v a l u a t i o n o f t h e e a r s a n d h e a r i n g , t h e p a t i e n t s h o u l d

b e a s k e d a b o u t a w a r e n e s s o f d e c r e a s e i n c o n v e r s a t i o n a l

h e a r i n g , a n d t h e e f f e c t t h a t b a c k g r o u n d n o i s e h a s u p o n

h e a r i n g ( C h a p t e r 1 2 0 ) . T h e h i s t o r y o f c h i l d h o o d e a r d i s e a s e

s h o u l d b e d o c u m e n t e d a l o n g w i t h h e a d , f a c i a l , o r e a r t r a u m a ,

e x p o s u r e t o o t o t o x i c d r u g s , p r e v i o u s e a r s u r g e r y , o r e a r

t r e a t m e n t , a n d t h e p r e s e n c e o f a n y s e v e r e f e b r i l e e a r i l l -

n e s s e s d u r i n g c h i l d h o o d . A c a r e f u l f a m i l y h i s t o r y f o r h e a r -

i n g i m p a i r m e n t , t h e u s e o f h e a r i n g a i d s , o r k n o w n e a r s u r g e r y

should be documented . T h e p a t i e n t s h o u l d b e a s k e d a b o u t

r e c e n t r e s p i r a t o r y i n f e c ti o n s o r a l l e r g y , a n d m e d i c a l t r e a t -

m e n t f o r s e v e r e a l l e r g y s h o u l d b e r e c o r d e d . Q u e s t i o n s a b o u t

e a r d r a i n a g e o r d i s c h a r g e , o r t h e p r e s e n c e o f e x c e s s i v e w a x ,

s h o u l d b e a s k e d . A n o c c u p a t i o n a l a n d r e c r e a t i o n a l h i s t o r y

s h o u l d b e t a k e n , p a r t i c u l a r l y r e l a t i n g t o e x p o s u r e o f t h e

p a t i e nt t o ex c e s s iv e n o is e . T h e q u a l i t y , d u r a t i o n , a n d t y p e

o f n o i s e s h o u l d b e d o c u m e n t e d , a n d t h e p a t i e n t ' s h u n t i n g

experience or other exposure to gunfire should be re-

corded . T h e f r e q u e n c y o f a i r c r a f t e x p o s u r e o r s c u b a d i v i n g

needs to be documented .

S y m p t o m s r e l a t e d t o t h e e a r s u c h a s r i n g i n g i n t h e e a r ,

o r t i n n i t u s ( C h a p t e r 1 2 1 ) , a r e v e r y c o m m o n , a n d s p e c i f i c

q u e s t i o n s s h o u l d b e a s k e d a b o u t d u r a t i o n , i n t e n s i t y , u n i -

l a t e r a l o r b i l a t e r a l p r e s e n c e , a n d p u l s a t i n g o r t h r o b b i n g

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5 90 I X . THE EAR, NOSE, MOUTH, AND THROAT

q u a li t y . F u l l n e s s i n t h e e a r s h o u l d b e d o c u m e n t e d , a n d b a l - T a b l e 1 1 9 . 2

ance disorders or vertigo require particular elaboration

(Chapter 123) . F r e q u e n t p r o b i n g o f t h e e a r f o r w a x r e m o v a l

o r i t c h i n g , o r t h e p l a c e m e n t o f f o r e i g n b o d i e s i n t h e e a r ,

should be documented . T h e p r e s e n c e o f p e r s i s t e n t p a i n i n

t h e e a r , o r o t a l g i a ( C h a p t e r 1 2 2 ) , o r k n o w l e d g e a b o u t d r u m

p e r f o r a t i o n s i n t h e p a s t , i s n e e d e d . Q u e s t i o n s r e l a t i n g t o

u n u s u a l s e n s i t i v i t y t o s u d d e n o r l o u d s o u n d s , p a r t i c u l a r l y

t h o s e a s s o c i a t e d w i t h o r r e l a t e d t o o t h e r e a r s y m p t o m s s u c h

a s t i n n i t u s , v e r t i g o , f u l l n e s s , o r f l u c t u a n t h e a r i n g l o s s , n e e d

t o b e r e c o r d e d . I n t e r m i t te n t , c h a n g i ng , o r f l u c t u a n t h e a ri n g

l o s s m a y b e p r e s e n t .

P h y s i c a l E x a m i n a t i o n

The instruments needed to study the head and neck are

l i s t e d i n T a b l e 1 1 9 . 1 . T a b l e 1 1 9 . 2 p r e s e n t s t h e s t e p s o f t h e

examination .

N o s e a n d P a r a n a s a l S i n u s e s

A n a s a l s p e c u l u m , a t r a n s i l l u m i n a t o r o n a b a t t e r y h a n d l e ,

a n d a s t e r i l e s w a b f o r c u l t u r e m a t e r i a l a r e n e e d e d f o r t h e

examination (Figures 119 .1 and 119 .2 ) . S o m e c l i n i c s h a v e

f i b e r o p t i c n a s o p h a r y n g o s c o pe s f o r e x a m i n a t i o n o f t h e s i n u s

o s t i a a n d n a s o p h a r y n x , a n d i t m a y b e n e c e s s a r y t o s e n d t h e

p a t i e n t f o r s c r e e n i n g s i n u s x - r a y s . S i n u s e x a m i n a t i o n s s h o u l d

always be done in a darkened area, and the use of a de-

congestant spray such as oxymetazolin or 0 .5% neosyn -

ephrine is encouraged .

D u r i n g e x a m i n a t i o n o f t h e n o s e ( C h a p t e r 1 2 8 ) , a c a r e f u l

e x t e r n a l i n s p e c t i o n s h o u l d b e c a r r i e d o u t w i t h n o t a t i o n m a d e

of any previous injury , trauma, or congenital defo rmity .

F r o n t a l a n d m a x i l l a r y s i n u s e s s h o u l d b e t r a n s i l l u m i n a t e d ,

a n d t h e s p e c u l u m s h o u l d b e u s e d t o e v a l u a t e t h e i n t r a n a s a l

T a b l e 1 1 9 . 1

Equipment Needed for Head and Neck Exa mination

M e t a l o r p l a s t i c n a s a l s p e c u l u m

C u r v e d t r a n s i l l u m i n a t o r o n b a t t e r y h a n d l e

D i s p o s a b l e w o o d e n t o n g u e d e p r e s s o r s

D e c o n g e s t a n t s p r a y s , s u c h a s o xy m e t a z o l i n e o r 0 . 5 %

n e o s y n e p h r i n e

S t e r i l e c o t t o n s w a b s f o r c u l t u r e

R u b b e r g l o v e s ( n o n s t e r i l e )

P e n l i g h t , e l e c t r i c o r f i b e r o p t i c h e a d l i g h t

No . 5 l a r y n g e a l m i r r o r ( m i rr o r w a r m e r o r h o t w a t e r )

S t a n d a r d w a x c u r e t t e ( b u c k c u r e t t e )

M e t a l e a r s y r i n g e o r s t a n d a r d 5 0 c c p l a s t i c s y r i n g e

S t a n d a r d p l a s t i c e m e s i s b a s i n

S m a l l t h i n w i r e a p p l i c a t o r w i t h t u f t s o f c o t t o n

S t a n d a r d e l e c t r i c o t o s c o p e w i t h c l o s e d l e n s a t t a c h m e n t t o p e r m i t

p n e u m a t i c m o v e m e n t o f t h e e a r d r u m w i t h a r u b b e r b u l b

E a r s p e c u l a e o f v a r i o u s s i z e s

H y d r o g e n p e r o x i d e o r a q u e o u s z e p h i r a n t o d i s s o l v e w a x

2 5 6 H z t u n i n g f o r k

Ancillary diagnostic equipment

E l e c t r i c a u d i o m e t e r

I m p e d a n c e b r i d g e

X - r a y e q u i p m e n t t o p e r m i t r o u t i n e C T a n d M R I v i e w o f t h e

h e a d a n d n e c k a r e a

F i b e r o p t i c n a s o p h a r y n g o s c o p e

Sequence of the Head and Neck Examinati on

F i g u r e 1 1 9 . 1

T r a n s i l l u m i n a t i on o f f r o n t a l s i n u s . L i g h t i s p l a c e d u n d e r s u p r a o r -

b i t a l r i m a n d t r a n s i l l u m in a t i o n o b s e r v e d t h r o u g h f r o n t a l b o n e .

N o s e a n d p a r a n a s a l s i n u s e s

O r a l c a v i t y a n d s a l i v a r y g l a n d s

J a w a n d t e m p o r o m a nd i b u l a r j o i n t s

P h a r y n x , l a r y n x , a n d t h y r o i d g l a n d s

T h e f a c e

E a r s a n d h e a r i n g

1 . I n s p e c t i o n o f t h e f a c e , h e a d , e a r s , a n d n e c k f o r d i s t i n c t i v e

2 .

p h y s i c a l s i g n s . N o t e u n u s u a l s p e e c h o r h e a r i n g r e s p o n s e s t o

q u e s t i o n s . N o t e p r e s e n c e o f g l a s se s o r h e a r i n g a i d s .

I n s p e c t i o n o f n a s a l c a v i t y f o r s e c r e t i o n s a n d m e m b r a n e

3 .

c h a r a c t e r i s t i c s w i t h n a s a l s p e c u l u m . R e p e a t a f t e r d e c o n g e s t a n t

s p r a y .

P a l p a t i o n , p e r c u s s i o n , a n d t r a n s i l l u m i n a t i o n o f m a x i l l a r y a n d

4 .

frontal sinuses .

I n s p e c t i o n o f o r a l c a v i t y a n d p h a r y n x w i t h l i g h t a n d t o n g u e

5 .

b l a d e . P a l p a t i o n o f s u b m a x i l l a r y a n d p a r o t i d g l a n d s ( e x t e r n a l

a n d b i n a u r a l w i t h g l o v e ) . N o t e c o n d i t i o n o f t e e t h o r u s e o f

d e n t a l p l a t e s ( r e m o v e t h e s e ) .

P a l p a t i o n o f T M j o i n t s , s u p e r i o r a n d i n f e r i o r t r i a n g l e s o f t h e

6 .

n e c k , c a r o t i d p u l s a t i o n , t h y r o i d g l a n d , a n d s u p r a c l a v i c u l a r

a r e a . A u s c u l t a t i o n f o r c a r o t i d b r u i t s .

I n s p e c t i o n o f f a c i a l s k i n , n o s e , p i n n a e , a n d s c a l p f o r c r u s t s ,

7 .

p i g m e n t e d l e s i o n s , u l c e r a t i o n s , c y s t s , e x c e s s i v e w r i n k l e s , e y e l i d

e d e m a o r s a g g i n g , a n d i n v o l u n t a r y m o v e m e n t s ( t i c ) .

I n s p e c t e a r a r e a f o r w a x o r s u r g i c a l s c a r s . R e m o v e a n y w a x

w i t h c u r et t e t h at o b s t r u ct s c l e a r v ie w o f e a r d r um . M o v e

e a r d r u m w i t h p n e u m a t i c o t o s c o p e a n d n o t e l i g h t r e f l e x .

P e r f o r m W e b e r a n d R i n n e t u n i n g f o r k t e s t s a n d r e c o r d

r e s u l t s . E x a m i n e f o r s e c r e t i o n s , c a n a l l e s i o n s s u c h a s b o n y

n o d u l e s , e a r d r u m s c a r s o r p e r f o r a t i o n s , d i s c o l o r a t i o n o r f l u i d

b e h i n d t h e d r u m , a n d p u l s a t i o n s . R e c o r d t h e n e e d f o r l o u d e r

c o n v e r s a t i o n , r e p e t i t i o n o f q u e s t i o n , o r l a c k o f r e s p o n s e

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Figure 119 . 2

Transillumination of maxillary sinus . T h e l i g h t i s p l a c e d a g a i n s t

the cheek and transillumination observed through the open mouth .

cavity (Figure 119 . 3 ) . A fiberoptic examination can be car-

ried out along with percussion and palpation over the max-

illary and frontal sinuses to denote tenderness .

O r a l C a v i t y a n d S a l i v a r y G l a n d s

Equipment needed inclu des a penlight or a headlight, dis-

posable tongue blades, a sterile swab for cul ture, and rubber

gloves for palpation (see Figure 119 . 4 ) . The patient may

need to have a CT scan of the salivary gland s, which can

be extremely helpful in evaluating occult lesions . Exami-

nation of this area shou ld include inspection of the palate,

tonsillar fo ssae, gums, tongue, cheeks, teeth, and the open-

ings of the submaxillary and parotid ducts (Chapters 129-

131) (Figures 119 .5 and 119 . 6) . Careful bimanual palpation

of the submaxillary gland ( Figure 119 .7) with palpation and

massage of the parotids (Figure 119 .8 ) w i t h o b s e r v a t i o n f o r

secretion from the ducts should be carried out .

Jaw and Temporomandibular Joints

Equipment needed to evaluate th is area of the body consists

of disposable tongue blades and the use of x-rays of jaw

joints in opened and closed position . Examination involves

careful palpation of the jaw joints at rest and in motion

(Figure 119 . 9) . The patient should be asked to bite dow n

firmly on a wooden tongue blade to see if this will elicit pain

in the joint . Tapping on the te eth with a met al probe may

help identify isolated dental disease that is referred to the

jaw joint area .

Pharynx, Larynx, and Thyroid Gland

Equipment includes disposable tongue blades, rubber gloves,

penlights and headlights , fiberoptic pharyngeal and lar-

1 1 9 . AN OVERVIEW OF THE HEAD AND NECK

Figure 119.3

U s e o f n a s a l s p e c u l u m t o v i s u a l i z e n a s a l c a v i t y a n d s e p t u m . Exudate

or disorders of the septum should be noted .

5 9 1

Figure 119 .4

U s e o f t o n g u e b l a d e t o s u p p r e s s o n e s i d e o f t o n g u e b a s e t o v i s u a l i z e

tonsil area and posterior pharyngeal area .

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592

Figure 119 .6

R e t r a c t i o n o f c h e e k t o s h o w o p e n i n g o f S t e n s e n ' s D u c t o pp os i t e

the second u pper molar .

I X. THE EAR, NOSE, MOUTH, AND THROAT

Figure 119 .5

Palpation of tonsillar fossa and base of tongue area with gloved hand . Unusual hardness, enlarge-

ment, or tenderness is noted

yngeal scopes, laryngeal mirrors, and sterile culture swabs .

X-ray is often utilized to document lesions around the lar-

ynx and pharynx, particularly CT scans of the neck . Rubber

gloves are used for palpation of the tonsillar fossa and base

o f t h e t o n g u e . Further palpation of the thyroid (Figure

119.10), larynx , and hyoid bone should be done (Chapter

132) . Mirror or fiberoptic examinations are vital in order

to document the motion of the vocal cords and lesions of

the epiglottis and larynx .

F a c e

Careful inspection of the face as a patient talks will reveal

many factors . The examiner should look carefully for signs

of trauma, previous facial surg ery, eye swelling, or "bags

under the eye," which might indicate fluid or allergic dis-

o r d e r s . The quality of the skin can be quickly noted . The

patient should be evaluated in the presence of good lighting

(preferably sunlight), and it is often helpful if cosmetic sur-

gery is to be considered to have frontal and profile pho-

tographs taken . Examination of the face involves in spection

for blepharochalasia (eyelid sa gging), excess wrinkling, or

redundancy of skin in various areas of the chin, neck, upper

neck, an d face . Regional inspection of the face should be

made to document skin lesions such as keratoses, moles, or

s c a r s . Facial asymmetry, nasal distortions, prominent ears,

m a l o c c l u s i o n ( o v e r b i t e o r u n d e r b i t e ), o r e x c e s s i v e h a i r s h o u l d

be documented . Enlargement in the sides of the face, whichindicates massete r hypertrophy or abnormal facial move-

ments such as tics, should be documented . The patient shoul d

have the face palpated for tenderness or protrusions, and

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