BATES’ VISUAL GUIDE TO PHYSICAL EXAMINATION

Vol. 7: Head, Eyes, and Ears

Your learning objectives for mastering the examination of the head, eyes, and ears are: to identify and
examine key structures basic to the head, eyes, and ears; to sharpen skills for assessing and describing
the patient’s general appearance, including facial expression, contours, and asymmetry; to be familiar
with the techniques of examination of the scalp and hair, including abnormalities; to accurately assess
visual acuity, extraocular movements, pupilary reaction, and auditory acuity; and to properly perform a
fundoscopic exam.

Anatomy Review—Head

With the patient’s health history in mind, you are now ready for the examination.

Before beginning, let’s review the important regions and structures of the head.

Regions of the head take their names from the underlying bones of the skull. The frontal area overlies
the frontal bone; the temporal area, the temporal bone; the parietal area, the parietal bone; and the
occipital area overlies the occipital bone. And the superficial temporal artery passes upward just in front
of the ear, where it is readily palpable.

Two pairs of salivary glands lie near the mandible: The parotid glands lie superficial to and behind the
mandible, and become both visible and palpable when enlarged. The submandibular glands are located
beneath the tongue, located deep to the mandible. The openings of the parotid and submandibular
ducts are visible within the oral cavity.

Common or concerning symptoms relating to the head, eyes, and ears include: Headache (one of the
most common symptoms in clinical practice); change in vision resulting in hyperopia, presbyopia,
myopia, or scotomatas; double vision (or diplopia); hearing loss, earache, or tinnitus; and vertigo.

By eliciting the patient’s concerns before the examination, you prepare for an examination that is
focused, efficient, and productive.

Examining the Head

After comprehensive hand hygiene, you are ready for the physical examination.

Because abnormalities covered by the hair are easily missed, ask the patient if they have noticed
anything wrong with the scalp or hair. If the patient is wearing a hairpiece or wig, ask the patient to
remove it.

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 Inspect the hair noting its quantity, texture, distribution, and pattern of loss if any. You may see loose
flakes of dandruff. Part the hair in several areas to inspect the scalp. Look for scaliness, lumps, nevi, or
other lesions.

Observe the general size and contour of the skull. Note any deformities, depressions, lumps, or
tenderness.

Learn to recognize the irregularities in a normal skull, such as those near the suture lines between the
parietal and occipital bones.

When examining the patient’s face, observe it at rest and during conversation, noting facial expressions
and contours, and observing for asymmetry, involuntary movements, edema, and masses.

Assess the color and condition of the skin on the face, noting its color, pigmentation, texture, thickness,
hair distribution, and any lesions.

Anatomy Review—Eyes

Before examining the patient’s eyes, let’s review their anatomy.

Note that the upper eyelid covers a portion of the iris, but does not normally overlay the pupil. The
opening between the eyelids is called the palpebral fissure.

The white sclera may look somewhat buff colored at its periphery. Do not mistake this color for
jaundice, which is a deeper yellow.

The conjunctiva is a clear mucous membrane with two easily visible components. The bulbar conjunctiva
covers most of the anterior eyeball. It adheres loosely to the underlying tissue and meets the cornea at
the limbus. The palpebral conjunctiva lines the upper and lower eyelids. The two parts of the
conjunctiva merge in a folded recess that permits movement of the eyeball.

Within the eyelids lie firm strips of connective tissue called the tarsal plates. Each plate contains a
parallel row of meibomian glands, which open on the lid margin. The levator palpebrae is the muscle
that raises the upper eyelid.

A film of tear fluid protects the conjunctiva and cornea from drying and infection. This fluid comes from
three sources: the lacrimal gland, the conjunctival glands, and the meibomian glands.

Tear fluid from the lacrimal gland above the eye drains medially through the lacrimal puncta and passes
into the lacrimal sac and onto the nose through the nasolacrimal duct. You can easily find the punctum
atop the small elevation of the lower lid medially. The lacrimal sac rests inside the bony orbit and is not
visible.

The cornea is the transparent, anterior portion of the outer covering of the eye. The muscles of the iris
control the size of the pupil. Muscles of the ciliary body control the thickness of the lens, allowing the

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 eye to focus on near or distant objects. The ciliary body also produces a clear liquid called aqueous
humor, which helps control the pressure inside the eye and drains out through the Canal of Schlemm.

The posterior part of the eye that is seen through the ophthalmoscope is called the fundus. The optic
nerve enters the eyeball posteriorly. You’ll find it with an ophthalmoscope at the optic disc where the
retinal arteries and veins converge . Lateral and slightly inferior to the disc is a darkened circular area
called the fovea. This surrounds a small depression in the retinal surface that marks the point of central
vision. The macula surrounds the fovea but has no discernible margins. Note the absence of retinal
vessels in much of this area.

The retina is the light-sensitive membrane that covers the fundus. A transparent mass of gelatinous
material called the vitreous body fills the eyeball and is not usually visible through the ophthalmoscope.
This helps maintain the shape of the eye.

To see an image, light reflected from the image must pass through the pupil and be focused on sensory
neurons in the retina. The image (represented here by the letter A) is projected on the retina upside
down and reversed left to right. Nerve impulses, stimulated by light, are conducted through the retina,
optic nerve, and optic tract into the brain.

Examining the Eyes

Begin the eye examination by assessing the patient’s visual acuity. Have the patient stand 20 feet from a
Snellen Eye Chart. Patients who use contact lenses or glasses should wear them. However, patients
should remove reading glasses, which can blur distance vision.

What I’d like you to do is hold this card in front of your left eye…

Okay.

…and then I want you to look at the chart and read the smallest line possible.

Okay. [READS CHART] D, E, F, P, O…T

Visual acuity printed at the side of the line of the eye chart and is expressed as two numbers (for
example, 20/20). The first number indicates the distance of the patient from the chart, and the second
number indicates the distance at which a normal eye can read the line of letters.

Repeat the test on the other eye.

For screening purposes, visual fields are tested by confrontation, which is a valuable technique for early
detection of lesions in the anterior and posterior visual pathway. Two tests are recommended.

For the static finger wiggle test, face the patient directly and imagine a glass bowl encircling her head
with the base of the bowl facing you.

Look directly into my eyes with both of your eyes.

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 Okay.

Ask the patient to look with both eyes into your eyes. Then, place your hands about 2 feet apart lateral
to the patient’s ears.

Slowly move your wiggling fingers of both hands along the imaginary surface of the bowl toward the
central vision line. Ask the patient to tell you as soon as she sees the finger movement.

Yes, I see it down there.

Map out the maximum lateral extent of the left and right monocular visual fields.

If you think you have found a visual defect, try to establish its boundaries, testing one eye at a time. For
instance, if you suspect a temporal defect in the left visual field, ask the patient to cover the right eye
and with the left eye, look into your eye opposite.

Then, slowly move your wiggling fingers from the defective area of the field toward the better vision,
noting where the patient first responds.

Repeat this at several levels until you can define the border of the defect. Then test the other eye for an
accompanying defect.

There, there…I see them there.

Next, for the Kinetic Red Target Test, face the patient and move a 5 millimeter, red-topped pin inward
from beyond the boundary of each quadrant along a line bisecting the horizontal and vertical meridians.
Ask the patient when the pin first appears to be red.

Visually inspect the patient’s eyes for position and alignment. Also, examine the eyebrows and closely
inspect the eyelids for the width of the palpebral fissures, edema and color of the lids, any lesions, and
the condition and direction of the eyelashes. Note the adequacy of eyelid closure, especially when the
eyes are unusually prominent, when there is facial paralysis, or when the patient is unconscious.

Inspect the area over the lacrimal gland and lacrimal sac for swelling. And look for excessive tearing or
dryness.

To inspect the sclera, and the conjunctiva, ask the patient to look up as you depress the lower lids with
your thumbs. Look for any nodules or swelling and inspect for color. Note the vascular pattern against
the white scleral background.

Ask the patient to look at each side and down. This will give you a good view of the sclera and bulbar
conjunctiva. If you need to view the palpebral conjunctiva of the upper lid, the eyelid must be everted.

With oblique lighting, inspect each cornea and lens for opacities. To do this, shine a penlight from the
side toward the eye.

At the same time, inspect each iris. Normally, iris markings are clearly defined. With your light shining
from the temporal side, look for a crescentic shadow on the medial side of the iris, which suggests
glaucoma.

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 Inspect the size, shape, and symmetry of the pupils. You can use a gauge with circles of varying sizes to
measure pupillary size.

Next, test the pupillary reactions to light. First, darken the room. Then ask the patient to look into the
distance. Shine a bright light obliquely into each pupil in turn. (The oblique lighting and the distant gaze
both help to prevent a near reaction.)

Look for the direct reaction, consisting of pupillary constriction in the eye being illuminated directly.

Then quickly swing the light to the other eye, looking for the consensual reaction, which is pupillary
constriction in the opposite eye.

If the reaction to light is questionable, test the near reaction in normal light. Testing one eye at a time,
hold a pencil or your finger about 10 centimeters from the patient’s eye. Ask the patient to look
alternately at it and into the distance directly behind it. Watch for pupillary constriction with near effort.

Next, assess ocular alignment arising from the extraocular muscles. From about 2 feet directly in front of
the patient, shine a light onto the patient’s eyes and ask the patient to look at it.

Inspect the reflections in the corneas. They should be visible slightly nasal to the center of the pupils.

Next, assess the extraocular movements, looking forthe normal conjugate movements of the eyes in
each direction, or any deviation from normal; nystagmus, a fine rhythmic oscillation of the eyes; and lid
lag as the eyes move up and down.

Ask the patient to follow your finger or a pencil as you sweep through the six cardinal directions of gaze.
Making a wide H in the air, lead the patient’s gaze to the patient’s extreme right, to the right and
upward…down on the right, then without pausing, up to the extreme left, then upward.

To detect horizontal, vertical, or rotatory nystagmus, look for a jerking movement of the eyes as the
patient looks to the far left, then the far right, then up and down.

If you suspect lid lag or hyperthyroidism, ask the patient to follow your finger again as you move it
slowly from up to down in the midline and look for a white rim of sclera above the iris.

Normally, the lid should overlap the iris slightly throughout this movement.

Test for convergence of the eyes by asking the patient to look at your finger as you move it toward the
bridge of the nose.

The eyes can usually follow your finger to within 5 to 8 centimeters of contact.

Next, after darkening the room, conduct your ophthalmoscopic examination. Switch on the
ophthalmoscope light and adjust it to the large, round beam of white light. Note that some examiners
prefer the smaller beam of light to avoid hippus, or spasm of the ciliary muscles. Also, make sure the
light is set to the appropriate brightness, often about 80% of full brightness to minimize pupillary
constriction. Initially set the ophthalmoscope to the zero diopter.

Ask the patient to look over your shoulder at a specific spot on the wall.

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 Remember to use your right eye and right hand as you examine the patient’s right eye. From 15 inches
away and 20 degrees lateral to the patient’s line of vision, shine the light beam on the pupil. Make sure
you can see clearly through the aperture.

You may wish to place the thumb of your other hand across the patient’s eyebrow to help keep you
steady.

Locate the red reflex, which should appear as an orange glow in the pupil. Note any opacities that
interrupt the red reflex.

While holding the red reflex in view, move in with the ophthalmoscope on the 15 degree angle toward
the pupil until the ophthalmoscope is close to the eye, almost touching your thumb.

Locate the yellowish-orange structure that is the optic disc.

If you do not see it at first, follow the retinal vessels centrally until you do.

Now, using your index finger, bring the optic disc into sharp focus by adjusting the lens of the
ophthalmoscope.

Note the color of the optic disc, the size of the central physiologic cup, and the clarity of the disc margin.
The cup to disc ratio, usually 1:3, can be elevated in glaucoma. Also note the comparative symmetry of
the eyes and fundi. Normally the optic disc is yellowish orange to creamy pink and round or oval with
well-demarcated margins.

Look for papilledema, which is a swelling of the optic disc and anterior bulging of the physiologic cup.
Papilledema often signals elevated intracranial pressure seen in mass lesions, meningitis, or
subarachnoid hemorrhage.

Moving your head and instrument as a unit, inspect the retina, including the arteries and veins as they
extend from the disc to the periphery.

Note the relative size and color of the narrower, lighter arteries and the larger, darker veins. Examine
the surrounding retina for lesions noting their size, shape, color, and distribution. Finally, examine the
fovea and surrounding macula by directing your light beam laterally or asking the patient to look directly
into the light. The tiny bright reflection at the center of the fovea may help orient you.

To focus on more anterior structures, such as opacities in the vitreous body or the lens, change the
diopter on the ophthalmoscope to more positive numbers such as +10 or +12.

Repeat the ophthalmoscopic examination on the patient’s left eye using your left hand and left eye.

Anatomy Review—Ears

Before examining the patient’s ears, let’s review their anatomy. The ear is composed of three
components: the external ear, the middle ear, and the inner ear.

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 The external ear includes the auricle and the ear canal. The auricle consists chiefly of cartilage covered
by skin. Its prominent curved outer ridge is the helix. Parallel and anterior to the helix is another curved
prominence called the antihelix. Inferiorly is the fleshy projection of the earlobe or lobule. The ear canal
opens behind the tragus and curves inward and is about 24 millimeters long.

The inner portion of the canal is surrounded by bone and lined by thin, hairless skin. Pressure here
causes pain, a point to remember when you examine the ear. At the end of the ear canal lies the
tympanic membrane (or eardrum). Behind and below the ear is the mastoid portion of the temporal
bone. The lowest portion of this bone, the mastoid process, is palpable behind the lobule.

The external ear captures sound waves for transmission into the middle and inner ear.

The middle ear is an air-filled cavity that transmits sound by way of the eardrum and three tiny bones or
ossicles: the malleus, the incus, and the stapes.

The inner ear contains the cochlea, the semicircular canals, and the distal end of the cochlear nerve.
Much of the middle ear and all of the inner ear are inaccessible to direct examination. These can be
assessed by testing auditory function.

Air conduction describes the normal first phase in the hearing pathway. An alternate pathway, known as
bone conduction, bypasses the external and middle ear and is used for testing purposes.

Examining the Ears

Begin the examination of the ear by inspecting the auricle and surrounding tissues for deformities,
lumps or skin lesions.

If ear pain, discharge, or inflammation is present, do the “tug test” to test for otitis externa, or external
otitis. Move the auricle up and down, press the tragus and press firmly on the mastoid bone behind the
ear. Tenderness here suggests mastoiditis.

Next, examine the ear canal and eardrum using an otoscope. To do this, select the largest speculum the
patient’s ear canal will accommodate.

Position the patient’s head so that you can see through the otoscope comfortably. To straighten the ear
canal, grasp the auricle firmly but gently and, in an adult, pull it upward, back, and slightly away from
the head.

Insert the speculum gently into the ear canal, directing it somewhat downward and forward, bracing
your hand against the patient’s face.

Note any cerumen (or ear wax) that may impair your view. Also, observe for any discharge, foreign
bodies, redness of the skin, or swelling.

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 Maneuver the speculum until you can see as much of the eardrum as possible, including the pars
flaccida, if possible, and the margins of the pars tensa. Note the color and contour of the eardrum with
its distinct cone of light. Normally, the drum is pearly gray.

Also, note the position of the handle of the malleus and inspect the short process of the malleus. The
handle of the malleus, with the umbo at its tip, crosses the eardrum obliquely from the cone of light
upward toward the short process. Be sure to examine the other ear in the same manner.

To assess hearing, ask the patient:

Do you feel you have a hearing loss or difficulty hearing?

If the patient reports hearing loss, proceed to the whispered voice test.

To assess hearing, test one ear at a time. Stand 2 feet behind the seated patient.

Occlude the non-test ear of the patient with your finger and gently rub the tragus in a circular motion to
prevent transfer of sound to that ear.

And now, tell me what I’m saying.

Exhale fully to ensure a quiet voice, and test the open ear by softly whispering a combination of three
numbers and letters. Gradually increase your volume until the patient can identify your words.

If the patient responds incorrectly, test a second time with a different number/letter combination.

In a normal response, the patient will repeat at least three out of the possible six numbers and letters
correctly. Repeat on the other side.

For patients failing the whispered voice test, a tuning fork test helps determine if the hearing loss is
conductive or neurosensory in origin. In a quiet room, select a tuning fork of 256 or 512 Hertz, as these
frequencies fall in the range of conversational speech.

Set the fork into light vibration by tapping it on your hand.

Test for lateralization by performing the Weber test. Place the base of a vibrating tuning fork firmly on
top of the patient’s head or on the mid-forehead. Then ask:

Is the sound louder in one ear, or the same in both ears?

It’s the same in both ears.

Normally, the sound is heard in the midline or equally on both sides.

Next, compare air and bone conduction by performing the Rinne test. Place a lightly vibrating tuning
fork on the mastoid bone behind the ear and level with the canal.

When the patient indicates that the sound is no longer heard, quickly place the vibrating fork near the
ear canal and ask if the sound can be heard.

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 The “U” of the fork should face forward, maximizing the sound for the patient. Normally the sound can
be heard longer through the air than through bone. Be sure to test the opposite ear.

Recording Your Findings

Remember that a clear, well-organized clinical record—employing language that is neutral, professional,
and succinct—is one of the most important adjuncts to patient care.

[TYPING] The skull is normocephalic and atraumatic. Hair has average texture. Eyes with visual acuity
20/20 bilaterally. Sclera white, conjunctiva pink…

After practice and further review of this video, make sure you have mastered the important learning
objectives for examining the patient’s head, eyes, and ears.

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