PHYSICAL EXAMINATION OF THE EYE, EAR, NOSE & THROAT

The HEENT (Head, Eyes, Ears, Nose, and Throat) examination is a fundamental component of the comprehensive physical assessment. It evaluates critical sensory organs, the upper respiratory tract, and initial structures of the gastrointestinal system. Because these structures are tightly packed and innervated by complex cranial nerves, a systematic and meticulous approach is essential.

By the end of this session, the learner should be able to:

1. Prepare the patient, environment, and equipment appropriately for a complete HEENT examination.
2. Perform a systematic examination of external and internal eye structures.
3. Assess visual acuity, visual fields, pupils, extraocular movements, and the fundus.
4. Examine the external and internal ear, and expertly assess hearing using bedside screening and tuning fork tests.
5. Examine the nose, sinuses, oral cavity, pharynx, and relevant neck structures (including lymph nodes and thyroid).
6. Distinguish expected normal findings from important abnormalities and critical clinical red flags.
7. Document findings clearly, concisely, and objectively, and communicate urgent abnormalities to the healthcare team.

A thorough examination always begins with a comprehensive history and proper preparation. Structure your approach to maximize patient comfort and clinical accuracy.

• Review the history first: Always gather subjective data before touching the patient. Ask about symptoms, exact time of onset, presence of pain, history of trauma, abnormal discharge, recent visual or hearing changes, seasonal allergies, current medications (especially ototoxic drugs or eye drops), and systemic diseases (like diabetes or hypertension which deeply affect the eyes).
• Explain, Consent, and Position: Explain every step of the examination in plain language, obtain informed consent, provide absolute privacy, and position the patient comfortably (usually seated upright at eye level with the examiner).
• Infection Control: Perform rigorous hand hygiene before and after the examination. Always use gloves when contact with mucous membranes, bodily secretions, or blood is expected (e.g., examining the oral cavity or draining ears).
• Adequate Illumination & Equipment: You cannot assess what you cannot see. Ensure bright ambient lighting and gather appropriate equipment: a strong penlight, visual acuity chart (Snellen), ophthalmoscope, otoscope, 512-Hz tuning fork, and tongue depressors.
• Compare Right and Left Sides: Clinical Tip: Always compare sides. The human body is relatively symmetrical. Comparing the symptomatic side to the asymptomatic side establishes the patient's unique baseline. Examine painful or injured areas last and very gently.
• Assess Function AND Structure: Do not just look at the anatomy; test what it does. Assess vision (acuity), eye movements (tracking), hearing (acuity and conduction), smell (olfaction) when indicated, swallowing (dysphagia), and speech articulation.

The eye examination proceeds from external inspection to functional visual testing, and finally to internal fundus examination.

• Penlight or focused light source.
• Visual acuity chart (Snellen chart for distance, near-vision card/Jaeger chart).
• Opaque occluder (to cover the eye not being tested).
• Ophthalmoscope.
• Optional: Fluorescein dye and cobalt-blue light (used in trained clinical settings to detect corneal abrasions or ulcers).
• Hand hygiene supplies and gloves (if discharge is present).

1. General inspection and external structures.
2. Visual acuity.
3. Visual fields by confrontation.
4. Pupils: size, symmetry, light response, and accommodation.
5. Extraocular movements (EOMs) and ocular alignment.
6. Conjunctiva, sclera, cornea, and anterior eye.
7. Ophthalmoscopy: red reflex, optic disc, vessels, retina, and macula.
8. Additional tests guided by specific symptoms or clinical indications.

• Inspect surroundings: Look at the eyebrows, eyelashes, eyelids, and lacrimal (tear) apparatus.
• Observe: Look for symmetry, abnormal eyelid position, swelling (edema), redness (erythema), lesions, crusting, and discharge.
  • Ptosis: Drooping of the upper eyelid (can indicate cranial nerve III palsy or myasthenia gravis).
  • Entropion: Inward turning of the eyelid margin, causing lashes to rub against and scratch the cornea.
  • Ectropion: Outward turning of the lower lid, leading to severe dry eyes and excessive tearing.
• Inspect Conjunctiva and Sclera: Gently pull down the lower lid to inspect the palpebral conjunctiva.
  • Look for conjunctival pallor (a classic sign of anemia), injection (redness/dilation of blood vessels), hemorrhage (subconjunctival bleeding), chemosis (swelling of the conjunctiva), and purulent discharge.
  • Inspect the sclera (the white of the eye) for icterus (yellowing, indicating jaundice/liver disease), diffuse redness, or localized nodular lesions.
• Subjective Assessment: Ask the patient directly about eye pain, photophobia (severe sensitivity to light), itching, a gritty "foreign-body" sensation, and any visual changes.

Visual acuity is the most vital sign of the eye. Never skip visual acuity testing just because a patient says they can "see normally." Reduced acuity can result from refractive errors, cataracts, corneal damage, retinal detachment, or optic-nerve disease.

• Procedure: Assess each eye separately first, then both eyes together if appropriate. Position the patient exactly at the chart distance specified (e.g., 6 meters or 20 feet for a standard Snellen chart). Ensure the chart is brightly illuminated.
• Testing: Test one eye at a time. Have the patient cover the opposite eye with an opaque occluder. Caution: Instruct the patient not to press directly on the occluded eye, as pressure can temporarily blur their vision when it is their turn to be tested.
• Ask the patient to read from the largest letters down to the smallest lines until they are unable to correctly identify the majority of symbols on a line.
• Near-Vision Testing: Use a near-vision card held at reading distance (about 35 cm) for patients over 40 complaining of reading difficulty (presbyopia).

This test screens for peripheral vision loss, which can indicate retinal detachment, optic-nerve damage, or brain lesions (like strokes or tumors in the optic chiasm).

• Technique: Sit facing the patient exactly at arm’s length. Have the patient cover one eye while you cover your directly opposite eye (e.g., patient covers their right eye, you cover your left eye). This establishes your visual field as the "normal" baseline to compare against theirs.
• Ask the patient to fixate their gaze directly on your open eye or your nose, and strictly instruct them not to move their eyes to follow the target.
• Bring a wiggling finger (or a red target) from the far periphery toward the center in all four quadrants (upper temporal, lower temporal, upper nasal, lower nasal).
• Ask the patient to say "now" the exact moment the target is first seen, and compare it with when you first see it in your own field. Repeat for the other eye.

Pupillary responses assess the autonomic nervous system and Cranial Nerves II (Optic - sensing light) and III (Oculomotor - constricting the pupil).

• Inspect: Note pupil size (in millimeters), shape (should be perfectly round), symmetry, and position.
• Light Response: Dim the room lights. Ask the patient to look at a distant object (to prevent accommodation constriction). Shine a bright penlight from the side into one eye.
  • Observe the direct response (the illuminated pupil constricts).
  • Observe the consensual response (the opposite pupil simultaneously constricts).
• Swinging Flashlight Test: Rapidly swing the light back and forth between the two eyes. This assesses for a Relative Afferent Pupillary Defect (RAPD), also known as a Marcus Gunn pupil, which suggests severe asymmetric optic-nerve or retinal disease. (Instead of constricting, the affected pupil appears to paradoxically dilate when the light swings to it).
• Accommodation: Ask the patient to fixate on a distant object, then quickly shift their focus to your finger held 10 cm from their nose. Observe for pupillary constriction and convergence (eyes turning inward).

This assesses the intricate coordination of Cranial Nerves III, IV, and VI, and the six extraocular muscles.

• EOM Testing: Ask the patient to keep their head perfectly still and follow your finger using only their eyes. Move the target smoothly through the six cardinal directions of gaze (forming a large "H" in the air), pausing briefly at the extremes.
• Observe for: Limitation of movement, asymmetry, nystagmus (involuntary, rhythmic twitching of the eye), and ask the patient if they experience diplopia (double vision) in any specific direction of gaze.
• Corneal Light Reflex (Hirschberg Test): Shine a light directly toward the bridge of the patient's nose from about 30 cm away. Compare the pinpoint reflection of light on each cornea. The reflections should be perfectly symmetric (slightly nasal to the center). Symmetric reflections suggest properly aligned visual axes.
• Cover Test: Used to screen for strabismus (ocular misalignment or "lazy eye"). Have the patient fixate on a distant target. Cover one eye and carefully observe the uncovered eye for any jumping movement (refixation). Then uncover the eye and observe it. Avoid forceful alignment testing if there is significant facial trauma.

• Anterior Eye: Re-inspect the cornea closely. A healthy cornea is perfectly clear, avascular, and smooth. Look for redness, embedded foreign bodies, ulcerations, cloudy opacities, or abnormal blood vessels growing into the cornea.
• Ophthalmoscopy Preparation: Darken the room. Ask the patient to stare at a fixed point on the distant wall. Use the ophthalmoscope in your right hand and use your right eye to examine the patient's right eye (to avoid bumping noses). Avoid pressing hard on the patient's eye.
• What to Assess:
  • Red Reflex: Shine the light at the pupil from 30 cm away. A healthy eye reflects a bright, symmetric red/orange glow. An absent or dark red reflex indicates an opacity blocking light (like a dense cataract or, in children, a dangerous retinoblastoma).
  • Follow the red reflex inward to locate the Optic Disc. Assess its color (yellow-orange), margins (should be sharp), and note any swelling (papilledema, a sign of dangerously high intracranial pressure).
  • Inspect the Retinal Vessels for caliber changes or crossing abnormalities (nicking, seen in hypertension).
  • Inspect the general Retina for hemorrhages (bleeding), exudates (yellow lipid deposits), or cotton-wool spots (infarctions), commonly seen in advanced diabetic or hypertensive retinopathy.
  • Inspect the Macula/Fovea last, by asking the patient to look directly into the light briefly.

The ear examination encompasses the external ear, internal canal and tympanic membrane (otoscopy), and bedside assessment of hearing pathways.

• Equipment: Otoscope with appropriate sized specula (use the largest comfortable speculum that fits the canal without causing pain), 512-Hz tuning fork, gloves when drainage/infection is indicated.
• Sequence: Inspect auricle ➔ Palpate external ear/mastoid ➔ Otoscopy ➔ Hearing assessment. (Always compare both ears).
• History: Ask specifically about ear pain (otalgia), discharge (otorrhea), hearing loss, ringing in the ears (tinnitus), dizziness/room-spinning (vertigo), feeling of fullness, trauma, and occupational noise exposure.

• Inspect the auricle (pinna) for size, position, symmetry, skin changes, crusting lesions (high risk area for skin cancer), swelling, and purulent or bloody discharge.
• Inspect the area directly behind the ear, including the bony mastoid region.
• Palpate: Firmly press the tragus (the small cartilage flap in front of the canal) and gently pull/move the pinna up and down. Pain with tragus/pinna manipulation strongly supports external canal inflammation (Otitis Externa or "Swimmer's Ear").
• Observe for congenital abnormalities (skin tags, pits), surgical scars, trauma (cauliflower ear), and skin disease.
• Caution: Avoid aggressive manipulation when significant head trauma or base-of-skull fracture is suspected.

• Technique: Position the patient comfortably with their head tilted slightly away from the ear being examined.
  • For adults: Gently pull the auricle up and back to straighten the S-shaped ear canal.
  • For infants/children under 3: Pull the auricle down and back.
• Hold the otoscope securely like a pen or pencil, and firmly brace the side of your hand or pinky finger against the patient’s cheek/head. This prevents sudden patient movement from driving the speculum deep into the delicate canal.
• Inspect the Canal: Look for excess cerumen (earwax), edema (swelling), erythema (redness), foreign bodies (common in children), discharge, and lesions. Advance gently without excessive pressure.
• Inspect the Tympanic Membrane (Eardrum):
  • Normal Appearance: Usually pearly gray, translucent, and shiny with a relatively smooth surface. The handle of the malleus (middle ear bone) should be visible through the drum. A bright, triangular "cone of light" reflection is often seen anteroinferiorly (around 5 o'clock in the right ear, 7 o'clock in the left ear). Assess color, position, translucency, landmarks, and structural integrity.
  • Abnormal Findings:
    • Bulging/opaque, fiercely red membrane with acute pain symptoms supports Acute Otitis Media (middle ear infection).
    • Retracted membrane (sucked inward, making bony landmarks highly prominent) may occur with chronic Eustachian tube dysfunction.
    • Perforation: A visible dark hole or defect in the drum; meticulously document its location, size, and any active discharge.
    • Air-fluid level or yellowish bubbles behind the drum suggest a middle-ear effusion (fluid buildup, common after colds or flights).
    • Foreign bodies, fungal debris (fuzzy spores), or severe canal edema narrowing the passage should be documented and managed appropriately.

• Whispered Voice Test: A simple, highly effective screening. Stand about 2 feet behind the seated patient (so they cannot read your lips). Ask them to occlude the non-test ear by rubbing the tragus. Exhale fully, and softly whisper a combination of 3 numbers and letters (e.g., "3-G-7"). Ask them to repeat it back. Test each ear separately. Patients who fail require formal audiologic assessment.

If hearing loss is detected, tuning fork tests help distinguish between Conductive Hearing Loss (problem in outer/middle ear blocking sound waves) and Sensorineural Hearing Loss (problem in the inner ear/cochlea or auditory nerve).

• History: Ask specifically about nasal obstruction, rhinorrhea (runny nose), epistaxis (nosebleeds), sneezing, itching, facial pain/pressure, loss of smell (anosmia), trauma, and seasonal allergies.
• Equipment: Penlight, nasal speculum (or an otoscope with a short, wide speculum tip), and gloves.

• Inspect the bridge, dorsum, tip, and alae (nostril wings) for obvious asymmetry, swelling, skin lesions, and discharge.
• Assess Patency: Ask the patient to firmly press one nostril closed and breathe in through the other. Repeat on the opposite side. Observe for noisy breathing, obstruction, or flaring of the nostrils (accessory muscle use, indicating respiratory distress).
• Characterize discharge: Is it clear and watery (allergies/viral), mucoid, thick and purulent/green (bacterial infection), or bloody?
• Trauma Assessment: After facial trauma, carefully inspect for deformity, severe swelling, epistaxis, and critically, a septal hematoma (a boggy, painful, cherry-red swelling on the septum that must be drained urgently to prevent cartilage necrosis and a "saddle-nose" deformity).

• Use a penlight or nasal speculum with excellent illumination. Do not insert instruments deeply or forcefully, as the nasal mucosa is highly vascular and extremely sensitive.
• Inspect: The nasal vestibule, the nasal septum, and the visible inferior and middle turbinates (bony ridges on the side walls).
• Mucosa: Normal mucosa is generally moist, intact, and pink.
  • Allergies (Allergic Rhinitis): Mucosa appears pale, bluish, boggy, and swollen.
  • Infection: Mucosa is bright red, erythematous, and swollen with purulent discharge.
• Look for crusting, severe ulceration, active bleeding, polyps (pale, benign, teardrop-shaped growths), foreign bodies, and gross septal deviation. Note that anterior septal bleeding commonly arises from Kiesselbach's plexus, a highly vascular area on the anterior nasal septum.

• Sinuses: Palpate and gently percuss the frontal (above eyebrows) and maxillary (cheeks) sinus regions. Apply firm upward pressure. Ask about tenderness or pain, and correlate with symptoms like fever and purulent discharge.
  • Red Flags: Unilateral severe facial pain/swelling, orbital swelling (swelling around the eye), or visual symptoms accompanying a sinus infection are highly concerning for orbital cellulitis and require prompt emergency assessment.
  • Note: Transillumination (shining a light through the sinuses in a dark room to look for glowing) is no longer routinely required as it has limited diagnostic accuracy compared to modern imaging.
• Smell Assessment (Cranial Nerve I): Test olfaction only when indicated by history or a full neurological exam. Use familiar, non-irritating odors (coffee, soap, vanilla). Test each nostril separately with eyes closed. Ask the patient to identify the odor, not just say they smell something. Avoid harsh irritants like ammonia, as they stimulate pain pathways via the trigeminal nerve rather than true olfactory receptors. Loss of smell can result from nasal obstruction, severe viral illness (like COVID-19), head trauma, or neurodegenerative disease.

• Ask about: Sore throat, dysphagia (difficulty swallowing), odynophagia (pain on swallowing), hoarseness, dental pain, mouth ulcers, bleeding gums, dry mouth, and relevant exposures (tobacco, alcohol).
• Equipment: Penlight and a clean wooden tongue depressor. Always wear gloves when examining the oral cavity, as contact with saliva and mucous membranes is guaranteed.
• Ask the patient to remove any dentures or removable orthodontic appliances to allow full visualization of the gums and palate.
• Crucial Airway Warning: Do NOT force a tongue depressor into the posterior pharynx of a patient (especially a child) presenting with severe airway symptoms, drooling, or stridor. This can trigger fatal airway spasms in conditions like epiglottitis.

• Lips: Inspect for color (cyanosis indicates hypoxia, profound pallor indicates anemia), hydration, symmetry, painful cracking at the corners (angular cheilitis), ulcers, or vesicular lesions (Herpes simplex/cold sores).
• Buccal Mucosa & Gums: Use a light and depressor to inspect the inside of the cheeks. Look for normal pink moisture, ulcers, bleeding gums (gingivitis), masses, or abnormal pigmentation.
  • Clinical Note: White, cheesy plaques that can be scraped off, leaving a red, raw, bleeding base, strongly suggest oral candidiasis (Thrush). Persistent, thick white lesions that cannot be scraped off (Leukoplakia) are considered precancerous and require biopsy evaluation.
• Teeth: Inspect for obvious caries (decay), discoloration, missing/broken teeth, and overall dental hygiene.
• Tongue (Cranial Nerve XII): Inspect the dorsum (top) for heavy coating, color, ulcers, and lesions. Ask the patient to stick their tongue straight out to assess symmetry and movement (it should not deviate to one side). Ask them to move it side-to-side.
  • Crucial Step: Inspect the lateral borders and the underside of the tongue (the floor of the mouth). Highly suspicious, cancerous lesions frequently hide underneath the tongue and can be easily missed if not specifically visualized. Persistent ulcers, firm induration (hardness), or unexplained masses require urgent oncology referral.

• Palate and Uvula (Cranial Nerves IX & X): Ask the patient to open wide and say a prolonged "ahhhh." Observe the soft palate and uvula. The palate should elevate symmetrically, and the uvula should remain perfectly midline.
• Tonsils: Inspect the tonsillar pillars and tonsils for size, fiery erythema, white/yellow exudate (pus), severe asymmetry, and lesions. Tonsils are graded on a scale:
  • 1+: Visible
  • 2+: Halfway to the uvula
  • 3+: Touching the uvula
  • 4+: "Kissing" (touching each other, severe airway risk)
• Posterior Pharynx: Inspect the back wall of the throat for extreme redness, swelling, "cobblestoning" (bumpy lymphatic tissue typical of post-nasal drip), exudate, or thick drainage.

• Voice: Listen carefully for hoarseness, severe muffling, a nasal quality, or dysarthria (slurred, thick speech).
• Swallowing: Ask about difficulty swallowing solids (often indicates mechanical obstruction/tumor), liquids (often indicates neurological/muscular disorder), or both. Distinguish actual pain on swallowing from a physical block. Observe them swallowing a sip of water if clinically appropriate and safe from choking.
• Airway: Look for drooling, stridor (high-pitched, harsh breathing sound indicating upper airway obstruction), severe respiratory distress, or inability to handle their own secretions. Acute airway compromise takes absolute priority over completing the rest of a routine HEENT examination.
• Neck & Lymph Nodes: Inspect the neck for visible swelling, masses, asymmetry, and skin changes. Systematically palpate the regional lymph node chains using the pads of your fingers in gentle, circular motions:
  • Submental, submandibular, tonsillar/jugulodigastric, anterior cervical chain, posterior cervical chain, and supraclavicular nodes.
  • Documentation: Describe nodes by exact location, size (in cm), tenderness, consistency (soft, rubbery, hard), mobility (freely movable or matted down), and distribution.
  • Clinical Clues: Tender, soft, mobile nodes usually occur with acute acute infection (e.g., strep throat). Hard, painless, fixed, persistent nodes, or any enlarged supraclavicular node (Virchow's Node), are highly suspicious for malignancy/cancer and require careful evaluation.

Putting the HEENT assessment together smoothly in a clinical encounter takes practice. A structured sequence prevents omission of critical steps.

1. Introduce yourself, confirm identity, explain procedure, and obtain consent.
2. General inspection: Facial symmetry, signs of distress, speech quality, and breathing effort.
3. Eyes: Visual acuity ➔ visual fields ➔ pupils ➔ EOMs/alignment ➔ external/anterior structures ➔ ophthalmoscopy.
4. Ears: External inspection/palpation ➔ otoscopy ➔ hearing screen ➔ Weber/Rinne when indicated.
5. Nose: External inspection ➔ patency ➔ internal inspection ➔ sinus assessment ➔ smell when indicated.
6. Mouth/throat: Lips ➔ oral mucosa ➔ teeth/gums ➔ tongue ➔ palate/uvula ➔ tonsils/pharynx.
7. Neck: Palpate lymph nodes and assess thyroid when indicated.
8. Summarize findings for the patient, thank them, ensure comfort, and perform hand hygiene.

• Failing to compare both sides for symmetry.
• Skipping visual acuity testing just because the patient says they can “see normally.”
• Pressing directly on the eye when occluding it for acuity testing (causing blurred vision).
• Using an otoscope aggressively without firmly bracing the hand against the patient’s head/cheek.
• Forcing an otoscope speculum or a tongue depressor against resistance or a gag reflex.
• Calling every single red eye “conjunctivitis” without ruling out serious causes via assessment of pain, photophobia, and visual loss.
• Documenting lazy phrases like “normal HEENT” instead of explicitly documenting the relevant normal and negative findings.
• Missing urgent, life-threatening symptoms because the routine sequence was prioritized over common sense and patient safety.

• STOP the examination immediately if the patient develops severe escalating pain, dizziness, respiratory distress, or significant anxiety.
• Do not diagnose solely from one isolated bedside sign; always integrate the comprehensive history, the full physical examination, and appropriate diagnostic investigations.
• Urgently escalate any suspected vision-threatening, airway-threatening, acute neurological, or major traumatic conditions to the senior medical team immediately.
• Strictly follow local referral pathways, your professional scope-of-practice, and all institutional infection-prevention requirements.
• Maintain dignity at all times: Explain each step before you perform it, preserve patient privacy, and use appropriate, respectful precautions.

• Bickley LS. Bates’ Guide to Physical Examination and History Taking. Wolters Kluwer. Current institutional edition.
• Jarvis C. Physical Examination & Health Assessment. Elsevier. Current institutional edition.
• American Academy of Ophthalmology (AAO): Clinical resources on eye examination and urgent eye conditions.
• American Academy of Family Physicians (AAFP): Resources on red eye, hearing loss, sinusitis, and oral/pharyngeal conditions.
• World Health Organization (WHO): Eye-care and hearing-care global resources.
• Note: Local Ministry of Health or specific institutional protocols must take precedence where they specify distinct examination parameters, referral pathways, or infection-prevention procedures.