History, Physical Examination, and the Preoperative Evaluation

Key Points

A careful history and detailed physical examination are the cornerstone of excellent patient care.
The operating microscope and rigid and flexible endoscopes are useful adjuncts to the basic head and neck examination. Establishing rapport with the patient prior to their utilization, especially in vulnerable patients, is critical to patient comfort, safety, and maximizing the information that can be obtained from the study.
Preoperative laboratory testing should be ordered based on findings from the directed history and physical examination, as well as the degree of anticipated surgical risk, and not on a routine basis.
Patients with active comorbid disease need a thorough preoperative evaluation. The otolaryngologist must work closely with the patient's primary care physician and appropriate subspecialists to ensure that a plan of action to mitigate associated increases in morbidity and mortality perioperatively is in place.
Routine perioperative antibiotics can be eliminated in most clean head and neck procedures that do not enter the aerodigestive tract, as well as straightforward clean-contaminated procedures, including adenotonsillectomy and septoplasty.
Bridging of patients on chronic oral anticoagulation therapy should be reserved for those at high risk for perioperative thromboembolism, including those with mechanical heart valves, active cancer, recent stroke, and severe coagulopathy.

The importance of obtaining a thorough history and physical examination cannot be underestimated. In many cases, a carefully conducted clinical evaluation can elucidate the diagnosis. In others, it is critical for directing further evaluation and for avoiding unnecessary testing. Careful consideration of the patient's presentation determines the urgency of further management and prevents potentially harmful delays in care. Otolaryngology–head and neck surgeons are privileged in the extraordinary amount of information that can be ascertained by a meticulous physical examination, because pertinent structures are easily accessed and extended evaluation tools, including fiberoptic endoscopes, are readily available.

Likewise, the preoperative evaluation is a vital part of surgical decision making. The patient's comorbidities and other relevant factors must be taken into account to accurately assess the risk involved in a surgical procedure, and these must be weighed in the analysis of whether benefits outweigh potential harms. By appropriately managing comorbidities perioperatively, risk can be decreased to the utmost extent possible, and operative complications can be reduced. Integral to this is an appreciation of the ideal set forth in the Hippocratic Oath: “Above all else, do no harm.” It is the surgeon's responsibility to ensure that appropriate patient assessment has been completed before entering the surgical suite.

Obtaining the History

The first step in gathering the patient history begins before the patient sets foot in the clinic, with a thorough review of patient records to include:

The referring physician's concern that prompted the patient's visit
Relevant laboratory values and diagnostic studies, including previously obtained radiographic images and reports
Previous operative and pathology reports
For malignant and unusual lesions, the original pathologic slides for review by the pathology department for a second opinion

Electronic health records (EHRs) are increasingly used and have the advantage of being more legible and less fragmented than paper records, and they are rapidly transferred electronically. However, a large amount of material is contained within the EHR, much of which is not directly relevant to the visit, which necessitates time to sift through. Variable formats among different software packages present the consulting physician with additional challenges in efficiently identifying important information within EHRs.

The physician should first determine and document the patient's chief complaint, which may differ from the referring physician's objective for the consultation. Addressing the patient's primary concerns is important in establishing rapport, increasing the efficiency and flow of the visit, and allowing the patient to participate in his or her own care. The latter is one of the central tenets of patient-centered care, an approach that may improve both patient satisfaction and health outcomes.

The history of the present illness expands upon the chief complaint. The physician must thoroughly understand the nature of the illness, including relevant temporal, aggravating, and relieving factors, past therapy, and the presence or absence of pain. In the head and neck, many organ systems are intertwined, and it is critical to ask about the impact of the disease process on related systems; for example, the presence of dysphagia in a patient with an airway complaint. As the practitioner listens to the patient, a picture emerges that includes a list of differential diagnoses to consider. Further questioning should be undertaken to begin to discriminate between items on this list.

A discussion of the patient's medical history leads the otolaryngologist to a better understanding of the patient and often reveals information that is important in the consideration of further workup and treatment. The practitioner should inquire about any previous emergency department visits, hospitalizations, and health problems that have required the care of a physician. A problem list of active health issues should be compiled and maintained, reflecting any changes that occur while the patient is under the otolaryngologist's care. A complete surgical history is important to obtain to understand the impact of comorbidities on the current complaint, to anticipate anatomic alternations, and to assess anesthetic risks that may be encountered, should further surgical treatment be undertaken. A history of difficult intubation is particularly important to elicit to anticipate any challenges that may arise in the operating theater.

Medication allergies are crucial to note prominently in the medical chart. True allergy should be distinguished from adverse effects of a medication. In addition, all medications and current dosages should be accurately recorded, and compliance with prescribed medications should be assessed. A history of noncompliance may need to be taken into account when deciding between courses of care, particularly when considering conservative management that would require close observation and follow-up.

A careful social history must be obtained, including:

Tobacco exposure. Note first- and second-hand exposure, and specifically ask about cigarette, cigar, and chewing tobacco consumption, either current or past use.
Alcohol consumption. Ask direct questions regarding the amount consumed, frequency, choice of beverage, and duration of use.
Past and current recreational and intravenous (IV) drug use
Sexual history. This is of particular importance in light of the role that human papillomavirus plays in some head and neck cancers. Assessing risk for human immunodeficiency virus, hepatitis C, and other sexually transmitted diseases is also important.
Other exposures. Occupational and vocational exposures to irritants, potential carcinogens, and noise should be elucidated if relevant to the chief complaint. A history of prior therapeutic irradiation, including modality (implants, external beam, or by mouth) and dosage should be ascertained. A history of accidental radiation exposure is also important to document.

Environment. An understanding of the patient's physical living environment and available social support is significant in assessing postoperative needs and appropriate disposition planning. Assessment of the patient's ability to perform critical activities of daily living is equally important. One frequently utilized tool, especially in head and neck cancer patients, is the Karnofsky Performance Status Scale ( Table 4.1 ).

TABLE 4.1

Karnofsky Performance Status Scale

From Hanks G, Cherny NI, Christakis NA, et al. Oxford textbook of palliative medicine, ed 4. New York, 2010, Oxford University Press.

Definition	%	Criteria
Able to carry on normal activity and to work; no special care is needed	100	Normal; no complaints; no evidence of disease
	90	Able to carry on normal activity; minor signs or symptoms of disease
	80	Normal activity with effort; some signs or symptoms of disease
Unable to work; able to live at home, care for most personal needs; a varying amount of assistance is needed	70	Cares for self; unable to carry on normal activity or to do active work
	60	Requires occasional assistance; able to care for most personal needs
	50	Requires considerable assistance and frequent medical care
Unable to perform self-care; requires equivalent of institutional or hospital care; disease may be progressing rapidly	40	Disabled; requires special care and assistance
	30	Severely disabled; hospitalization is indicated, death not imminent
	20	Very sick; hospitalization necessary; active supportive treatment necessary
	10	Moribund; fatal processes progressing rapidly
	0	Dead

The family history is often quite revealing, and asking patients questions about their familial history of hearing loss, congenital defects, atopy, or cancer may uncover pertinent information that may alter the direction of evaluation.

Finally, a review of systems is part of every comprehensive history. This review includes changes in the patient's respiratory, cardiac, neurologic, endocrine, gastrointestinal, urogenital, musculoskeletal, cutaneous, and psychiatric systems. A review of all the elements of the complete history is given in Box 4.1 .

Box 4.1

History

Introduce yourself

Review

Medical records
Radiographic images
Laboratory values
Pathology specimens

Inquire About Chief Complaints

Location
Duration
Temporal characteristics
Aggravating and relieving factors
Related complaints

Review Patient History

Medical history
Surgical history
Allergies
Medications
Social history
Living situation
Family history

Risk Factors

Tobacco and alcohol use
Drug use
Sexual practices

Review Systems

Respiratory
Cardiac
Neurologic
Endocrine
Gastrointestinal
Urogenital
Musculoskeletal
Skin
Psychiatric

Physical Examination

The otolaryngologist must develop an approach to the head and neck examination that allows the patient to feel comfortable while the physician performs a complete and comprehensive evaluation. Many of the techniques used by the otolaryngologist may leave a patient feeling alienated if not done correctly. Thus it is essential to establish a rapport with a patient before proceeding with the examination.

The hands should be washed before and after each examination. Portions of the head and neck examination should only be done with the examiner wearing gloves and, in some instances, protective eye covering. Universal precautions are mandatory in today's practice of medicine and have the added benefit of showing the patient that the examiner is concerned about disease transmission, which builds trust.

General Appearance

Much information can be gleaned by assessing the general behavior and appearance of the patient. An assessment of the vital signs should be conducted. The level of alertness and orientation should be noted, as well as the presence of signs of distress or toxicity, such as increased work of breathing, diaphoresis, and rigors. The patient's affect may suggest psychiatric issues such as depression, anxiety, or frank psychosis. Acute intoxication may be evident and may obviate the patient's ability to consent to the examination or treatment. Poor personal hygiene may be a clue to a difficult home environment or even homelessness, which the patient may have been reluctant to directly disclose when discussing social history. Tar-stained fingernails, teeth, or moustache are harbingers for heavy tobacco consumption. Disturbed gait and ability to navigate the examination room may point toward potential vestibular or neurologic impairment.

Head and Facies

The head should be examined for overall shape, symmetry, and signs of trauma. Areas of hair loss should be noted if relevant, and scalp lesions should be identified. Facial skin is inspected for signs of sun damage, lesions, and the presence of rhytids. The face is analyzed for the presence of dysmorphic features. Facial symmetry is evaluated, both at rest and with motion. The American Academy of Otolaryngology–Head and Neck Surgery Facial Nerve Grading System is a respected standard for reporting gradations of nerve function ( Table 4.2 ).

TABLE 4.2

American Academy of Otolaryngology–Head and Neck Surgery Facial Nerve Grading System

Grade	Facial Movement
I	Normal	Normal facial function at all times
II	Mild dysfunction	Forehead: moderate to good function
		Eye: complete closure
		Mouth: slight asymmetry
III	Moderate dysfunction	Forehead: slight to moderate movement
		Eye: complete closure with effort
		Mouth: slightly weak with maximum effort
IV	Moderately severe dysfunction	Forehead: no movement
		Eye: incomplete closure
		Mouth: asymmetric with maximum effort
V	Severe dysfunction	Forehead: no movement
		Eye: incomplete closure
		Mouth: slight movement
VI	Total paralysis	No movement

The facial skeleton—including the bony nasal dorsum, orbital rims, malar eminences, maxilla, and mandible—should be carefully palpated for bony deformities, irregularities, and step-offs; this is especially important in patients with recent facial trauma. The regions overlying the paranasal sinuses may be firmly palpated or tapped for tenderness, which may be present during an episode of sinusitis. The temporomandibular joint is evaluated by placing the examiner's fingers over the temporomandibular joint region anterior to the external auditory canal and asking the patient to open and close the jaw. Dislocation, locking, or clicking of the joint is consistent with an intraarticular disk disorder, which can be responsible for otalgia and headache.

The parotid gland should be inspected for overlying skin changes or gland enlargement and to identify visible masses. The glands are then palpated to detect tenderness and characterize any masses, including location, size, mobility, and compressibility. Bimanual palpation with a gloved hand inside the oral cavity allows further evaluation of masses, as well as expressing saliva from Stenson's duct, important in suspected sialadenitis or sialolithiasis. The preauricular and retroauricular lymph nodes should be systematically assessed.

Eyes

The shape and angulation of the palpebral fissures are noted, along with any rounding of the canthi or increase in intercanthal distance. The conjunctiva and sclera are inspected for any infection, swelling, or discoloration. The eyelids are assessed for retraction and lid lag, which can be consistent with hyperthyroidism. The presence of strabismus or spontaneous nystagmus is noted, and extraocular movements are evaluated to provide an assessment of the oculomotor, trochlear, and abducens nerves, and gaze-evoked nystagmus. The pupils are assessed for response to light and accommodation. In some cases, fundal examination may be important and can indicate the need for more detailed ophthalmologic examination.

Ears

Auricles

The postauricular region should be inspected for healed surgical incisions. Clinical signs of mastoiditis that include tenderness, erythema, and fluctuance should be sought in the patient with otalgia and fever. In trauma patients, ecchymosis overlying the mastoid (Battle sign) is indicative of temporal bone fracture.

The position and shape of the pinna should be noted, including any asymmetry present. The overlying skin should be examined for evidence of erythema, drainage, and crusting consistent with infection. Psoriasis of the auricle or external auditory canal with its attendant flaking, dry skin, and edema is another common finding. Ulcerations and rashes can be consistent with viral infections as a result of herpes simplex and herpes zoster. Signs of solar damage and lesions consistent with skin cancer should be noted and warrant biopsy. Loss of the normal cartilaginous landmarks is seen in inflammatory and infectious lesions, as well as in the setting of auricular hematoma. Pain upon manipulation of the pinna indicates inflammation or infection of the pinna or external auditory canal.

The areas anterior to the root of the helix and tragus may have preauricular pits, sinuses, or skin tags. Any drainage should be noted.

External Auditory Canal

The outer third of the auditory canal is cartilaginous, with fairly thick skin that contains hair follicles, sebaceous glands, and apocrine glands that produce cerumen. The inner two-thirds of the canal is osseous and has only a thin layer of skin overlying the bone. To visualize the ear canal, gently grasp the pinna and elevate it superiorly and posteriorly to straighten the canal and allow atraumatic insertion of the otoscopic speculum. The overall patency of the canal should be evaluated; difficulty in inserting a properly sized speculum could indicate the presence of stenosis that may be congenital or acquired in nature.

Cerumen commonly accumulates in the canal, often obstructing it; this may require careful removal to ensure complete examination. The color and consistency of drainage or debris should be noted, and cultures should be considered. Foreign bodies may be found, with the majority lateral to the isthmus, and should be removed with an operating microscope. Disk-style batteries need to be removed emergently. Once the canal is clear of debris, the quality of the ear canal skin should be evaluated. Erythema and edema in the setting of white, moist debris is consistent with otitis externa. In older patients, atrophy of the external auditory canal skin is frequently seen and may be associated with psoriasis or eczema of the canal. In addition, any masses or skin lesions should be noted. Cutaneous cancers, such as squamous cell carcinoma, can involve the ear canal skin, and careful documentation and biopsy of any lesions should be undertaken. The presence of granulation tissue at the junction of the cartilaginous and bony canal should raise concern for malignant otitis externa, particularly in patients who have diabetes or in those who are immunocompromised. Lacerations may be present in the setting of trauma, which may include temporal bone fractures.

Tympanic Membrane

The tympanic membrane should be visible after the canal has been cleared of any debris. As depicted in Fig. 4.1 , the membrane is oval and cone shaped, and it is surrounded by the fibrous white annulus. The central portion of the membrane attaches to the handle of the malleus, which terminates in the umbo. The lateral process of the malleus is readily seen in the superior tympanic membrane and will be quite prominent in retracted membranes. Superior to this process is the pars flaccida, wherein the tympanic membrane lacks the radial and circular fibers present in the pars tensa, which comprises the remainder of the eardrum. The pars flaccida must be critically examined, because it is the most common location for retraction pockets, debris, and cholesteatoma. The normal tympanic membrane should be pearly gray and translucent, which allows examination of the structures of the middle ear, including the promontory and round window. The stapes and eustachian tube opening are visible in some ears. The clinician must also assess for areas of myringosclerosis, which appear as chalky white patches, frequently seen in regions of previous trauma. A thickened, erythematous membrane, occasionally with bullae, is consistent with myringitis; but a thin, atelectatic membrane draped closely over the underlying middle ear structures may indicate adhesive otitis media, and prominent radial blood vessels can indicate a chronic middle ear effusion. Perforations should be noted with their location, proximity to the annulus, and approximate size expressed as a percentage of the drum perforated.

Pneumatic otoscopy should be performed, particularly when middle ear disorders are of concern. First, an appropriately sized speculum is used to seal the ear canal. With gentle pressure from the pneumatic bulb, the tympanic membrane will move back and forth, if the middle ear space is well aerated. With a retracted drum, it is helpful to depress the bulb prior to sealing the canal to generate negative pressure. Perforations and middle ear effusions are common causes of immobile tympanic membranes.

The middle ear should be assessed for the presence of any fluid. Serous effusions often appear as amber fluid, sometimes with air-fluid levels or air bubbles. Mucoid effusions will appear dull gray to white in color, with loss of the typically visualized middle ear landmarks, and the tympanic membrane will often be retracted. White masses, often with associated perforation and granulation tissue, are consistent with acquired cholesteatoma. A white pearl behind an intact tympanic membrane, often in the anterior-superior quadrant, is likely to represent congenital cholesteatoma. Vascular masses should prompt consideration of middle ear glomus tumor; the clinician may also note a Brown sign, in which the mass blanches with pneumatic otoscopy.

Hearing Assessment

Tuning fork tests, usually done with a 512-Hz fork, allow the otolaryngologist to distinguish between sensorineural and conductive hearing loss ( Table 4.3 ). Tuning fork tests have a role in assessing hearing when an audiogram is not available, as well as in confirming audiometric findings. All tests should be conducted in a quiet room without background noise and in ears cleared of cerumen and debris.

TABLE 4.3

Tuning Fork Testing

Weber	Weber “Negative”	Weber Right
Weber	Sound is midline (“negative”): normal	Sound localizes right or left: ipsilateral conductive or contralateral sensorineural hearing loss
Rinne	Air > bone conduction: normal or ipsilateral mild sensorineural hearing loss	Bone > air conduction: ipsilateral conductive hearing loss
Example: 1 Right conductive hearing loss: Weber lateralizes to right; Rinne on right bone > air 2 Right sensorineural loss: Weber lateralizes to left; Rinne air > bone bilaterally
Rinne	Rinne “Positive”	Rinne “Negative”
Patient response	“Sound is louder when the fork is by the canal.”	“Sound is louder when the fork is on the mastoid process.”
Interpretation	Air conduction louder than bone conduction; normal	Bone conduction louder than air conduction; conductive hearing loss

Begin with a 512-Hz fork; then include 256- and 1024-Hz forks.

The Weber test is performed by placing the vibrating 512-Hz tuning fork in the center of the patient's forehead, at the bridge of the nose, or on the central incisors with the patient's teeth tightly clenched. The patient then is asked if the sound is louder in one ear or is heard in the midline. The sound waves should be transmitted equally well to both cochleae through the skull. A unilateral sensorineural hearing loss causes the sound to lateralize to the ear with the better cochlear function. However, a unilateral conductive hearing loss causes the Weber test to lateralize to the side with the conductive loss, because less competing background noise is detected through air conduction. A midline Weber result is referred to as “negative.” “Weber right” and “Weber left” refer to the direction to which the sound lateralized.

To further elucidate the nature of unilateral hearing loss, the Rinne test is performed. The 512-Hz tuning fork is placed firmly on the mastoid process, and patients are instructed to tell the examiner when they are no longer able to hear the sound. The fork is then quickly transferred in front of the ear canal, and patients are asked if they can again hear sound. If the sound is still audible, it is deemed a positive test, indicating that air conduction is greater than bone conduction; this is seen in ears with a mild sensorineural loss, as well as normal hearing ears. If the sound is no longer heard when the tuning fork is placed in front of the canal, bone conduction is deemed greater than air conduction, and this is termed a negative Rinne test consistent with conductive hearing loss . These tests can be repeated with the 256- and 1024-Hz tuning forks; negative responses provide an indication of the degree of conductive hearing loss ( Table 4.4 ).

TABLE 4.4

Tuning Fork Assessment of Degree of Hearing Loss

Hearing Loss (dB)	256 Hz	512 Hz	1024 Hz
<15	+	+	+
15–30	–	+	+
30–45	–	–	+
45–60	–	–	–

+: positive Rinne, air conduction > bone conduction.

−: negative Rinne, bone conduction > air conduction.

Nose

The external nose should be inspected from the frontal, profile, and base views for any deformity or asymmetry. The projection of the tip and dorsum and the width of the alar base are considered. The soft tissue envelope is inspected for skin quality and thickness, and for the presence of any lesions or discoloration.

Anterior rhinoscopy using a headlamp and nasal speculum allows assessment of the nasal septum and inferior turbinates. The speculum should be directed laterally to avoid touching the sensitive septum with the metal edges. Drainage, clot, and foreign bodies should be noted. The anterior septum, where numerous small branches of the external and internal carotid arteries meet (Kiesselbach plexus), should be evaluated for prominent, superficial ectatic vessels that may be responsible for epistaxis. Anterior septal deviations and bony spurs are often evident, and palpation of the anterior septum with gloved fingers can be helpful in determining the presence of caudal deviation. The characteristics of the mucosa of the inferior turbinate may range from the boggy, edematous, pale mucosa seen in those with allergic rhinitis to the erythematous, edematous mucosa seen in those with sinusitis. Polyps and masses may be visualized and warrant endoscopic examination. The patency of the nasal airway bilaterally should be noted.

Nasal endoscopy using rigid endoscopes allows thorough examination of even the most posterior portions of the nasal cavity but carries a risk of laceration in an uncooperative patient. After applying a local anesthetic and topical decongestant spray, the rigid zero-degree endoscope may be passed into the nose along the nasal floor, noting the appearance of the septum, inferior turbinate, and eustachian tube orifice. The appearance of the mucosa following decongestion is noted, and it is compared with the appearance on anterior rhinoscopy. The endoscope is then removed and reintroduced above the inferior turbinate to view the middle turbinate, and is again passed posteriorly to the nasopharynx. The tip is withdrawn to the head of the middle turbinate and is then directed laterally to view the lateral nasal side wall, when the patient is able to tolerate this. Accessory ostia from the maxillary sinus may be visible and often are mistaken for the true maxillary ostium, which is located behind the uncinate and is not usually visible. In patients who have undergone endoscopic sinus surgery, many of the sinus ostia can be evaluated endoscopically. The procedure is then repeated on the other side. Flexible fiberoptic scopes can also be used and are safer in young children and other unpredictable patients, but these often provide inferior optics and are less able to be directed into the lateral and superior aspects of the nasal cavity.

Nasopharynx

The nasopharynx extends from the skull base to the soft palate, and this can be a challenging area to examine. In the patient with a high posterior soft palate and small tongue base, the otolaryngologist may use a small dental mirror and a headlamp to visualize the nasopharynx. By having the patient sit upright in the chair, the physician may firmly pull the tongue forward while opening the patient's mouth to place the mirror just posterior to the soft palate. The structures of the nasopharynx are seen when the mirror is oriented upward.

Utilization of a fiberoptic nasopharyngoscope allows excellent visualization of this area. The midline also should be inspected for any masses, ulcerations, or bleeding areas. Another technique uses a 90-degree rigid scope, which is advanced through the mouth, with the beveled edge placed posterior to the soft palate; the nasopharynx may be seen in its entirety, and both compared for symmetry using this technique.

Regardless of the technique used, the adenoids, eustachian tube orifice, torus tubarius, and fossae of Rosenmüller should be inspected on each side. Whereas children have adenoid tissue present, adults should not have much adenoid tissue remaining in this area; the presence of tissue should prompt consideration of lymphoma or human immunodeficiency virus (HIV) infection. All patients with unilateral otitis media should have their nasopharynx inspected for possible nasopharyngeal masses. Nasopharyngeal carcinoma most commonly presents in the fossa of Rosenmüller. In young male patients, nasopharyngeal angiofibromas are locally aggressive but histologically benign masses that most commonly occur in the posterior choana or nasopharynx. Cysts in the superior portion of the nasopharynx may represent a benign Tornwaldt cyst or a malignant craniopharyngioma.

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