The physical exam of the head and neck is both simple and challenging

No great artist ever sees things as they are. If he did, he would cease to be an artist.
-Oscar Wilde

The physical exam of the head and neck is both simple and challenging. Simple, in that even children are familiar with the shape of the face, the sheen of the eye, the curve of the ear, and the texture of the tongue. Challenging, because when complicated, interlacing structures malfunction, they send mixed and subtle messages.

Last month, over 200 second-year medical students descended on the ENT clinic for an afternoon. We supplied lights, ear specula and tongue depressors. They supplied the energy and curiosity as they practiced peeking in each other’s ears and throats. Some brought along their brand new $400 otoscopes. Most will never spend another minute working with me or my colleagues to learn the head and neck examination.

Is the physical exam even important anymore?

A recent story on National Public Radio confirms that some physicians skip the physical exam because they find that the quick 15 minutes allotted to an office visit is better spent engaged in conversation and reviewing test results. They also acknowledge that some of the parts of the examination are so difficult and subjective that an expensive test (for example, a $600 echocardiogram) might be more reliable than using a stethoscope to diagnose a murmur or extra sound.

The modern, technology-savvy doctors are probably correct, but, when it comes to a decent physical exam, I am painfully old-fashioned. I really enjoy the process of discovery that the exam provides by melding physical findings with the patient’s story to arrive at a diagnosis. It is far from a perfect science, but it is important work at which we can only improve with practice. The “laying on of hands” remains a big part of what I do in the office.

A friend of mine told me about returning to see a doctor that was caring for her broken ankle. “I saw the physician three times and he never actually touched my leg! My ankle healed up just fine, but it seemed odd that he examined me only by looking at my X-rays. Is that typical?”

I do not know what is typical anymore.

During my training, we flocked to learn from the gifted diagnosticians — the curious, thorough, patient, and perceptive teachers who could use their hands, ears and sense of smell to arrive at an obscure diagnosis. Even as technology pushes to every corner of medicine, I am hopeful that we will always have those master clinicians among us.

Bruce Campbell is an otolaryngologist who blogs at Reflections in a Head Mirror.

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  • http://doctorstevenpark.com Steven Park, MD

    There’s a certain healing property to touching a patient. Even for routine follow-up visits, I make any excuse to examine the patient so that I can make some kind of physical, skin to skin contact. Even post-op in the recovery room, a gentle hand on the shoulder, or a firm grasp of the hand is much appreciated by the patient. Studies have shown that preemies that are touched more often leave the neonatal ICU quicker. Why can’t this be applied to adults as well? It’s clear that there’s now less art and more science in medicine.

    On another note, over the years I can predict a patient’s medical history pretty accurately just by looking at their facial structures and the oral cavity exam. The smaller (or narrow) the jaws, and the less space there is for the tongue, the more likely they won’t be able to sleep on their backs, and more likely to have conditions such as anxiety, depression, migraines, sinus problems, TMJ, reflux, and fatigue. Many patients with these features will have a high arched hard palate, deviated nasal septum, and tongue scalloping (which alone can predict apneas with high accuracy). Not all will have sleep apnea (not now), but most will have significant sleep problems due to frequent breathing obstructions and arousals. Parents of these patients will almost always have sleep apnea. A quick endoscopic exam with the patient supine will reveal a very narrow posterior airway space.

    I write about this and the sleep-breathing paradigm in my book, Sleep, Interrupted.

    http://doctorstevenpark.com

  • http://www.drmartinyoung.com Martin Young

    You are so right. I am amazed at how quickly a full ENT examination can be carried out with the proper training and methodology, including ‘specialist’ procedures like endoscopic and microscopic examinations. A few minutes is all it takes – far shorter than a detailed history, but just as critical.

    I am equally amazed at how badly trained many of my new young colleagues are at doing the same exam, missing extensive carcinomas, not even seeing the eardrum with an otoscope.

    Some how the ears, nose, throat, neck, and larynx are considered far less important than the heart, liver or spleen in academic training institutions.