A Review of the HEENT System: Head, Eyes, Ears, Nose, and Throat
The head, eyes, ears, nose, and throat (HEENT) system assessment commences the family nurse practitioner’s (FNP’s) subjective and objective evaluation of the patient. Its initiation reveals first impressions uncovered by both the family nurse practitioner (FNP) and the patient. Since it is the introduction of the patient interview and bodily examination, the FNP’s aptitude and professionalism during these processes lay out the foundation of the patient’s feelings of solace, care, and security while under professional care. Proficiency and knowledge of each system component are essential for identifying normal and abnormal data regarding specific populations, disease processes, and if applicable, treatment options.
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The purpose of this paper is to identify each structure within the HEENT system, discuss the physiology of the HEENT system and its organs, identify relevant health history questions to obtain subjective data, recognize objective data and normal physical examination findings, identify special physical examination techniques and procedures specific to the HEENT system, and discuss specific physical examination accommodations for specified populations. Lastly, a discussion of one major disease process and its expected abnormal physical examination findings as it relates to the HEENT system will be identified.
Identification of the HEENT System Structures
Expertise in the assessment of the HEENT system structures permits an effortless interview and physical examination of the patient. The five system structures contain distinct characteristics that the FNP must identify during routine examinations of both asymptomatic and symptomatic patients. The HEENT system alone reveals pertinent information regarding the patient’s sense of smell, sight, hearing, touch, and taste. Although limited entirely to the patient’s head, subjective and objective findings may necessitate obligatory assessments of further body systems to confirm significant associations. A discussion of the organs contained within the HEENT system is necessary to appreciate their significance.
The head is composed of the skull bones, muscles, arteries and veins, lymphatic nodes, and facial structures. It contains the pathways for examining the remaining structures of the HEENT system. The skull possesses a unique responsibility of protecting the inner components of the head, including the brain (Jarvis, 2016). The muscles of the head allow for the exhibition of facial expressions which are pertinent for interpreting pain during an observational physical assessment of the patient. To sustain proper functioning of the organs confined within the head, arteries and veins supply blood to and from each structure to maintain homeostasis. Lymphatic nodes within the head are scattered among the structures and aid in regulating the immune system by identifying and ridding foreign substances (Jarvis, 2016). The facial structures maintain specific duties to preserve the proper functioning of the head and its organs. The neck and its muscles provide stability to the head and its structures. The thyroid gland and lymphatic nodes are also contained within the neck.
The eyes uphold an important task by producing sight and are protected by varying structures to maintain integrity. Bilateral eyelids function as mobile shields and protect the eyes from injury and powerful light sources. Continuous lubrication is provided by the lacrimal apparatus to sustain moisture of the cornea and conjunctiva (Jarvis, 2016). The bony orbits are cavities which encompass the eyeballs and provide durable protection from outside sources. Extraocular muscles attached to the eyeballs allow for paralleled movement toward a desired point of interest (Jarvis, 2016). The sclera, choroid, and retina form the internal anatomy of the eyes, and provide protection, visual processing, and signaling to the brain with each eye movement.
According to Jarvis (2016), the ears are sensory organs which allow for hearing, balance, and maintaining equilibrium. Three parts make up the ear’s anatomy, including the external ear, the middle ear, and the inner ear. Together, these components permit the movement of sound into the ear and terminate as vibrations at the tympanic membrane for cochlear processing (Jarvis, 2016). Once processed by the cochlea, the vibrations are transmitted into the basilar membrane where numerous hair receptors of the organ of Corti transform the vibrations into electrical impulses for interpretation by the brain’s cortex (Jarvis, 2016). This process produces the sensory impulse that human’s recognize as sound.
Jarvis (2016) signifies the importance of the nose as it provides moisture, filtration, and inhalation of oxygen. It is the beginning of the respiratory system and permits patency through both nostrils for adequate delivery of air into the lungs. Hair receptors exist within the nasal cavity and allow for the sense of smell to be interpreted by the temporal lobe of the brain (Jarvis, 2016). Communication between the sinuses within the skull allows for protective mechanisms, such as mucus production, in times of illness. The nose plays an important role in preventing the invasion of foreign bodies and bacteria into the body.
Also known as the pharynx, the throat contains organs which hold important immunological functions of the body. The tonsils are large masses of lymphoid tissue that provide protection from bacteria and other pathogens attempting to enter the body (Jarvis, 2016). The pharynx terminates toward both the esophagus and trachea, two organs which provide the consumption of food and air. The throat plays an important role in the diagnosis of various viral and bacterial infections.
Obtaining the Health History: Subjective Data
According to Krautter et al. (2017), obtaining the patient’s health history establishes the foundation for the therapeutic patient-provider relationship. Relevant health history questions about the patient’s HEENT system provide subjective information provided in the patient’s own words. If necessary, the FNP can utilize quotations marks when documenting specifics about a patient’s own statements regarding their health. If the patient verbalizes pain during the interview, a focused assessment should be conducted to identify each aspect of pain, including onset, location, duration, characteristics, aggravating factors, relieving factors, and treatment.
The FNP should ask the patient about previous head injuries, head trauma, dizziness, or headaches. Questions about lumps or swelling may reveal the necessity for special attention to the area during the physical assessment. Information obtained about the patient’s eyes should include a history of difficulty or changes in vision, pain, irritation, redness, or discharge. Information about earaches, ear infections, and discharge should be obtained. If the patient confirms a history of hearing loss, specialized tests should be conducted during the physical examination to determine the likelihood of hearing impairment. The FNP should ask about nasal discharge or trauma, sinus pain, and inquire about a history of frequent cold viruses. The FNP should obtain information about allergies, including food, drug, environmental, seasonal, and latex allergies. Subjective data about the throat should include information about a history of sore throats, lesions, hoarseness, and dysphagia. The FNP should also obtain information about the use of smoking and alcohol consumption as these can impair the natural integrity of the HEENT system. Lastly, subjective data should be obtained about the patient’s health maintenance behaviors for each HEENT structure.
Normal Physical Examination Findings: Objective Data
Expected findings during a normal HEENT assessment include a round, symmetric skull that is proportionate to the patient’s body with the absence of bumps, lesions, and masses. Inspection of the face will reveal symmetry and observation of the patient’s facial expression. Assessment of the neck reveals a midline head position with a full range of motion. The trachea, thyroid gland, and lymphatic nodes can be palpated within the neck. Visual acuity, visual fields, and intraocular muscle function are tested by utilizing special examination techniques. Inspection of the external ocular structures will reveal symmetry between the eyes. The eyeballs will be aligned, glossy, and moist with no protruding or sunken appearances. The sclera of the eye will be white, and the conjunctiva will be clear. There will be no swelling of the lacrimal apparatus. The pupils will be round with normal constriction and dilation. Inspection of the ocular fundus will reveal a round, yellow-orange optic disc with distinct margins. Retinal vessels will be paired with no observation of arterial constriction or venous dilation. The ears will be equal in size bilaterally with no visual abnormalities. The tympanic membrane will be shiny, translucent, and emit a pearly-gray color. Hearing acuity is confirmed by special examination techniques. The nose will be symmetric with adequate patency upon sniffing inward. There will be no discharge from the nasal cavity, and the septum will be midline. Palpation of the sinuses will reveal no tenderness. There will be no mouth, teeth, gum, or tongue changes. Inspection of the throat will reveal pink, oval tonsils with the absence of exudate, and the uvula will present at midline.
Special Physical Examination Techniques and Procedures
Four important physical examination techniques are necessary for conducting a satisfactory assessment. Inspection, palpation, percussion, and auscultation are conducted in this order to assess each aspect of the patient’s physical appearance. Inspection is the process of observing with the FNP’s own eyes and provides the first impression of the patient. Palpation utilizes the provider’s sense of touch to assess for normal bodily features, such as temperature and texture, while also providing insight into the presence of swelling, inflammation, or masses. Percussion elicits palpable vibrations and sounds of underlying structures and is conducted by utilizing the provider’s own hands to produce results. Auscultation is conducted by utilizing a stethoscope to assess sounds produced by the body, such as the lungs, abdomen, and heart (Jarvis, 2016).
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Specialized examination procedures are conducted for specific bodily systems. The HEENT system examination requires various techniques to assess for pertinent objective data. An important examination of the eye involves the utilization of an ophthalmoscope to inspect the ocular fundus. This examination will uncover a wide range of findings involving the optic disc, retinal vessels, and general background of the fundus. The ophthalmoscope is also utilized to elicit the red reflex when assessing for cataracts. The Snellen eye chart is utilized to measure a patient’s visual acuity, while the confrontation test assesses for a loss in peripheral vision. When assessing the ears, the FNP utilizes an otoscope for inspection of the tympanic membrane. Hearing acuity is assessed by conducting the whispered voice test and tuning fork tests. The Rinne and Weber tests utilize tuning forks to assess for conductive and sensorineural hearing loss.
Accommodations for Specific Populations
Although the FNP may have tailored the health history and physical assessment to allow for a smooth, uninterrupted flow, specific populations require accommodations and adaptations of a personalized examination routine. Infant, pediatric, pregnant, and geriatric populations will require adjustments to the FNP’s customary examination. The FNP should be knowledgeable of the expected normal physical examination within each population to ensure appropriate recognition of developmental findings.
For infant and pediatric populations, assessment of the HEENT system requires precise measurements of head size, palpation of fontanels, and facial characteristics. Abnormalities found should be investigated further for potential growth retardation, increased intracranial pressure, or developmental delay. Awareness of the infant’s or child’s age is essential to determine the appropriate screening measures for visual acuity. The FNP should be familiar with the proper approach when assessing a child’s ear. Rather than pulling the pinna up and back as with adults, the FNP should pull the pinna straight down when inserting the speculum tip of an ophthalmoscope into the ear. Due to its intrusive process, inspection of the throat and ear should be completed toward the end of the physical examination (Jarvis, 2016). Allowing the parent or caretaker to be involved with the FNP’s physical examination may aid in relieving stress in younger populations.
The sole bodies of pregnant women are accommodating for two individuals, both themselves and the newborn baby, therefore changes in the HEENT system are likely to be observed during the physical examination. Hyperpigmentation of the face is common in women who are in their second trimester (Jarvis, 2016). Hypertrophy of the gums is a frequent occurrence in pregnant women as well. Palpation of the thyroid gland in pregnant women is common, although unusual masses or lumps should be investigated.
While the geriatric population once possessed the normal physical examination findings the FNP would expect in their customary routine examination, changes should now be anticipated. Assessment of the geriatric patient’s range of motion in their neck should be conducted slowly as this could provoke dizziness. Mild tremors may be noted upon inspection of the head and are typically benign. Diminished visual acuity and a loss of tone to ocular structures are expected findings. The FNP should inquire whether the patient has been having frequent falls which could be attributed to their vision impairment. Examination of the ocular fundus may reveal drusen deposits which are benign, round, yellow spots scattered about the retinal surface (Jarvis, 2016). Corneal changes may be apparent upon the first impression of the patient. High-tone hearing loss is common among the aging population. Receding gum margins and noticeably yellow teeth may be present.
Strep Throat and the Expected Abnormal Physical Examination Findings
Strep throat is a common disease process encountered by the FNP within the primary care clinic. Its causative organism, group A beta-hemolytic Streptococcus (GABHS), possesses the ability to alter the normal functioning of the HEENT system in all populations. If left untreated, GABHS can lead to rheumatic fever, a disease with the power to severely damage the patient’s bodily systems beyond the HEENT structures (Ahmad, Saleemi, & Iqbal, 2018). The primary HEENT structure affected by GABHS is the throat. A patient with GABHS may present with a fever, sore throat, and dysphagia.
Expected abnormal physical examination findings in a patient diagnosed with GABHS involve abnormal vital signs, throat changes, and lymph node swelling and tenderness. Upon taking the patient’s vital signs, it is common to observe a fever. Objective throat findings include tonsil enlargement, white or yellow exudate on the pharynx and tonsils, and a bright erythematous throat (Jarvis, 2016). Swelling and tenderness to the anterior cervical and tonsillar lymph nodes is often present. In pediatric patients presenting with GABHS, vomiting can occur (Alp et al., 2018). Confirmation of the above physical examination findings can be achieved by conducting a rapid antigen swab test (Alp et al., 2018). If the presence of GABHS is confirmed, appropriate treatment with antibiotics and symptom management is necessary.
When conducting the patient interview and physical assessment, the HEENT system is the initial body system to be exposed by the patient. The FNP possesses a duty to ensure each component of the interview and examination is orchestrated with careful consideration to maintain a comfortable patient environment. The HEENT system provides insight into the initial characteristics of the patient’s health history and physical examination findings. Incorporating subjective and objective data elicits information about the patient’s well-being or lack thereof. Specific populations require intellect beyond the standard expected findings within a health history and physical examination. These populations exhibit normal alterations which should be anticipated upon evaluation of the patient. Certain disease processes have the potential to alter the HEENT system’s structure and function. Strep throat is commonly encountered in the primary care setting and has distinct abnormal physical examination findings, which guide the FNP toward the appropriate diagnosis and plan of care.
- Ahmad, W., Saleemi, M. Y., & Iqbal, M. (2018). B-hemolytic streptococcal pharyngitis: Diagnosing group A b-hemolytic streptococcal pharyngitis (strep throat) by brisk antigen detection. Professional Medical Journal, 25(12), 1882-1886. doi:10.29309/tpmj/18.4585
- Alp, E. E., Dalgic, N., Kina, N., Bayraktar, B., Oncul, A., & Sepetci, E. A. (2018). The importance of rapid antigen testing for group A streptococcal tonsillopharyngitis: A single center experience. Journal of Pediatric Infection, 12(3), e93-e98. doi:10.5578/ced.201829
- Krautter, M., Diefenbacher, K., Schultz, J., Maatouk, I., Herrmann-Werner, A., Koehl-Hackert, N., . . . Nikendei, C. (2017). Physical examination skills training: Faculty staff vs. patient instructor feedback: A controlled trial. PLOS One, 12(7), e180308. doi:10.1371/journal.pone.0180308
- Jarvis, C. (2016). Physical examination & health assessment (7th ed.). St. Louis, MO: Elsevier
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