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Chapter 2
Primary Care Otolaryngology
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