This part of the examination can be done with the patient seated on the end of the examining table facing the doctor. The type of chair designed for ear, nose, and throat examinations can be used if available but is by no means necessary.

Fig. 5. Location of. A, salivary and thyroid glands and, B, lymph nodes.

Fig. 6. Technique for palpation of glands and lymph nodes.

The doctor should adjust his headlight, face the patient, and do the following:

1. Inspect the skin of the head and neck area as well as the lips for suspicious lesions, swelling, or asymmetry. Nasal passages should be inspected with the aid of a nasal speculum.

2. Palpate with the finger tips:

(a) The region of the parotid and submaxillary salivary glands; also the cervical and supraclavicular lymph nodes (Figs. 5 and 6)

(b) The thyroid gland

(1) Grasp the gland between the thumb and index and middle fingers of one hand and carefully palpate at rest and during swallowing (Fig. 7, A). (2) Displace the gland with the thumb first to one side and then the other, palpating with the index and middle fingers of the opposite hand (Fig. 7, B).

Fig. 7. Techniques for palpation of the thyroid gland.

Fig. 8. Inspection of the mouth with a tongue blade.

(3) Stand behind the patient, grasp the gland between the finger tips of the opposing hands, and palpate at rest and during swallowing (Fig. 7, C).

(4) Check for substernal extension of the gland and tracheal displacement.

(5) Observe for presence of enlargement, nodularity, induration, etc.; it sometimes helps to palpate the gland while the patient is swallowing a few sips of water.

3. Inspect the mouth with the use of a headlight and a tongue blade (Fig. 8). Remove any dentures first! Inspection should include:

(a) Lips

(b) Buccal mucosa

(c) Gums

(d) Roof of mouth

(e) Floor of mouth

(f) Tongue

(g) Tonsils if present

(h) Pharynx

4. Palpate the oral cavity, especially the nonvisible areas at the base of the tongue, using a finger cot (Fig. 9).

5. Inspect the larynx and surrounding area with a mirror, especially in heavy smokers. After a little practice, the so-called indirect laryngoscopy without topical anesthesia can be done with good visualization in about one third of all patients; inspection will be only fair in another third; in the remainder the larynx will remain inaccessible because of an active gag reflex, the presence of an overhanging epiglottis, etc. In the absence of clinical suspicion of laryngeal disease, attempts to visualize the area may stop here. (Measures used to ensure adequate examination of the larynx when disease is suspected are detailed in Chapter IV (Head And Neck), Head and Neck.) Inspection of the larynx and surrounding area is done as follows:

Fig. 9. Palpation of the oral cavity using a finger cot.

(a) Tell the patient what you are going to do and how you are going to do it. Urge him to

(1) Relax

(2) Breathe through his mouth

(b) Adjust the focus of the headlight to ensure a well-lighted spot in the pharynx.

(c) Heat the face of a medium-sized laryngeal mirror over a flame or in hot water to avoid fogging. Wipe it clean and allow it to cool to the point of tolerance (test on undersurface of the wrist).

(d) Have the patient stick out his tongue.

(e) Wrap gauze around the tongue.

(f) Grasp the tongue with your left hand between the thumb and middle finger.

(g) Pull the tongue out and down gently but firmly, using the left index finger to keep the mouth open. (Some have the patient hold the gauze and his tongue.)

(h) Insert the mirror with the reflecting surface angled down and in the direct beam of the headlight (Fig. 10). Avoid touching the tonsillar area to minimize the gag reflex. Steady the handle of the mirror on the commissure of the mouth.

(i) Inspect the larynx and adjacent structures (Fig. 11). (j) Have the patient say

(1) "eeeeee"

(2) "aaaaaa"

(3) "uhhhhh"

Fig. 10. Correct insertion of the mirror for examining the larynx and surrounding area.

Fig. 11. Inspection of the larynx and surrounding area (see also Fig. 40, p. 101).

This allows observation of vocal cord movement and exposes some relatively inaccessible areas to inspection, (k) In some patients it is possible to visualize the nasopharynx by rotating the mirror (or a smaller one) so that it faces upward behind the uvula.