What is the recommended approach for a HEENT (Head, Eyes, Ears, Nose, Throat) exam and management plan?

Comprehensive HEENT Examination and Management Approach

A thorough HEENT (Head, Eyes, Ears, Nose, Throat) examination should follow a systematic approach that evaluates each component methodically, with specific attention to anatomical structures and common pathologies in each area. 1

Head Examination

Inspection

• Observe for facial symmetry, skin lesions, dysmorphic features
• Note any swelling, masses, or visible deformities
• Assess scalp for lesions, alopecia, or inflammation

Palpation

• Palpate skull for tenderness, masses, or deformities
• Examine temporal arteries and temporomandibular joints
• Check for lymphadenopathy in preauricular, postauricular, occipital regions

Eye Examination

External Examination

• Inspect eyelids for swelling, erythema, ptosis, or lesions
• Look for excessive lacrimation, erythema of conjunctiva
• Note presence of "allergic shiners" (venous stasis below lower eyelids)
• Check for proptosis or enophthalmos

Visual Assessment

• Assess visual acuity using Snellen chart when appropriate
• Evaluate extraocular movements and pupillary responses
• Perform fundoscopic examination when indicated

Ear Examination

External Ear

• Inspect auricles for deformities, lesions, or inflammation
• Check for tenderness or swelling of the tragus or mastoid process

Otoscopic Examination

• Assess ear canal for cerumen, foreign bodies, discharge, or inflammation
• Evaluate tympanic membrane for:
  • Color (normal, erythematous, yellow)
  • Position (neutral, retracted, bulging)
  • Integrity (intact, perforated)
  • Mobility (using pneumatic otoscope)
• Consider tympanometry to assess middle ear function 1

Nose Examination

External Nose

• Inspect for deformities, inflammation, or discharge
• Note any external crease (allergic salute)

Internal Examination

• Use nasal speculum or otoscope with wide tip
• Assess nasal mucosa for color, edema, discharge, or lesions
• Evaluate nasal septum for deviation, perforation, or ulceration
• Check for nasal polyps or foreign bodies
• Consider nasal endoscopy for better visualization when available 1

Sinus Assessment

• Palpate and percuss sinuses for tenderness
• Transilluminate sinuses when indicated

Throat/Oral Cavity Examination

Oral Cavity

• Inspect lips, buccal mucosa, gums, teeth, and tongue
• Note any lesions, ulcerations, or abnormal coloration
• Check for dental malocclusion or high-arched palate

Oropharynx

• Examine tonsils for size, exudates, or asymmetry
• Look for pharyngeal erythema, postnasal discharge
• Assess for palatal movement during phonation
• Note any cobblestoning of posterior pharyngeal wall 1

Neck Examination

• Inspect for masses, asymmetry, or visible pulsations
• Palpate for lymphadenopathy, thyroid enlargement
• Assess range of motion and any associated pain 1

Special Considerations for Specific Conditions

For Allergic Rhinitis Evaluation

• Focus on nasal mucosa appearance (pale, boggy, edematous)
• Look for "allergic shiners" and transverse nasal crease
• Note clear, watery rhinorrhea
• Assess for concurrent conjunctival injection 1

For Sinusitis Evaluation

• Check for purulent nasal discharge
• Assess for sinus tenderness
• Consider imaging studies (CT sinuses with contrast) for chronic cases 1

For Otitis Media Evaluation

• Carefully assess tympanic membrane appearance
• Use pneumatic otoscopy to assess membrane mobility
• Consider tympanometry when available 1

Diagnostic Testing Considerations

When to Consider Imaging

• CT sinuses with contrast for suspected chronic sinusitis or structural abnormalities
• MRI orbit/brain with contrast for suspected orbital or intracranial complications
• High-resolution CT chest for suspected pulmonary involvement in systemic conditions 1

Laboratory Testing

• Consider specific IgE testing (skin or blood) for suspected allergic etiology
• Complete blood count with differential for suspected infection
• Inflammatory markers (ESR, CRP) when systemic inflammation is suspected 1

Management Approach

For Allergic Rhinitis

1. Environmental control measures
2. Intranasal corticosteroids (first-line pharmacotherapy)
3. Oral or intranasal antihistamines (second-line)
4. Consider allergen immunotherapy for persistent symptoms 1

For Chronic Rhinorrhea in Children

1. Nasal saline irrigation as first-line treatment
2. Add intranasal corticosteroids if symptoms persist
3. Avoid oral decongestants and first-generation antihistamines in young children due to safety concerns 2

For Sinusitis

1. Appropriate antibiotic therapy for bacterial infection
2. Intranasal corticosteroids
3. Saline irrigation
4. Consider surgical consultation for chronic/recurrent cases 1

Common Pitfalls to Avoid

1. Failing to perform a complete examination of all HEENT components
2. Overlooking subtle findings that may indicate systemic disease
3. Misdiagnosing allergic symptoms as infectious
4. Overuse of antibiotics for viral upper respiratory infections
5. Inadequate follow-up for persistent symptoms
6. Missing signs of potential malignancy or serious pathology

Documentation Recommendations

A thorough HEENT examination documentation should include:

• Specific findings for each anatomical area
• Positive and pertinent negative findings
• Any diagnostic tests performed and results
• Assessment and differential diagnosis
• Management plan with specific treatments
• Follow-up recommendations

By following this systematic approach to HEENT examination and management, clinicians can ensure comprehensive evaluation and appropriate treatment of conditions affecting these anatomical areas.