INTRODUCTION — Examination of the head, eyes, ears, nose, and throat (HEENT) in children will be reviewed here. Other aspects of the pediatric physical examination are discussed separately.
Visual inspection — The initial part of the head, eyes, ears, nose, and throat (HEENT) examination includes assessment of the head shape (figure 1), presence and distribution of hair, scalp defects, abnormalities of sutures, abnormal lesions or protuberances, lacerations, and abrasions or contusions.
Lumps and bumps on the head may arise from soft tissue or bone.
●Firm or hard masses include exostoses and calcified hematomas (image 1). (See "Nonmalignant bone lesions in children and adolescents", section on 'Osteochondroma and hereditary multiple osteochondromas'.)
●Soft tissue masses include:
•Dermoid cysts (picture 1) (see "Skin nodules in newborns and infants", section on 'Dermoid cysts and sinuses')
•Encephaloceles (picture 2) (see "Primary (congenital) encephalocele", section on 'Clinical features')
•Infected scalp lesions
•Intradiploic epidermoid cysts – Intradiploic epidermoid cysts are rare, congenital bone masses most frequently located in the skull (picture 3). They are derived from ectodermal cell rests in bone during embryogenesis. The diagnosis is suggested by the characteristic radiographic finding, a well-defined lesion with sclerotic borders . Although these lesions are benign and grow slowly, prophylactic removal is generally recommended because they can increase in size and may be complicated by abscess formation, bleeding, intracranial extension with neurologic manifestations, and malignant change .
Head circumference — Head circumference should be measured at each regularly scheduled well-child visit throughout the first 24 to 36 months of life. Young children may dislike having their head circumference measured and it may be best to postpone the measurement until the end of the examination. The technique for head circumference measurement and head circumference reference standards are discussed separately. (See "The pediatric physical examination: General principles and standard measurements", section on 'Head circumference'.)
Anterior and posterior fontanelles — Palpation of the anterior and posterior fontanelles is performed with the patient in the upright position.
●The anterior fontanelle is located at the juncture of the metopic, sagittal, and coronal sutures (figure 2). Generally, it is 3 to 6 cm (1.2 to 2.4 inches) in diameter through the first six months of life.
●The posterior fontanelle is located at the juncture of the sagittal and lambdoid sutures (figure 2). Usually, it is no larger than 1 to 1.5 cm (0.4 to 0.6 inches) in diameter.
Both fontanelles normally are soft and relatively flat. Visible or palpable pulsations of the anterior fontanelle are common, especially in the crying or agitated infant. Pounding pulsations or persistent tenseness of the fontanelle may indicate increased intracranial pressure. A depressed or sunken anterior fontanelle is compatible with dehydration or malnutrition. (See "Elevated intracranial pressure (ICP) in children: Clinical manifestations and diagnosis", section on 'Clinical manifestations' and "Clinical assessment of hypovolemia (dehydration) in children", section on 'Estimating degree of hypovolemia'.)
●Normal closure – The normal time of fontanelle closure depends upon the patient's gestational age at birth. The posterior fontanelle usually cannot be palpated after two months of age [3,4]. The anterior fontanelle generally closes between 10 and 24 months of age . The fontanelles of premature infants tend to close at a later time. Growth of fibrous tissue over the fontanelle precedes closure by several months and may be difficult to distinguish from true closure on physical examination.
In a cross-sectional study, high-resolution computed tomography (CT) scans of the head in young children (0 to 24 months of age) who were born at term were retrospectively reviewed for anterior fontanelle closure and surface area . The scans were performed for evaluation of clinical findings (eg, trauma, seizure, altered mental status); children with conditions associated with potentially altered anterior fontanelle geometry (eg, hydrocephalus, achondroplasia, craniosynostosis) were excluded. The proportion with anterior fontanelle closure increased steadily after five months of age:
•5 to 9 months – 3 percent
•10 to 12 months – 21 percent
•13 to 15 months – 35 percent
•16 to 18 months – 60 percent
•19 to 21 months – 84 percent
•22 to 24 months – 89 percent
These findings suggest that there is substantial variability in the timing of closure of the anterior fontanelle and that early or delayed closure may be a normal variant.
●Early closure – Early closure of the anterior or posterior fontanelle is not uncommon in an otherwise normal child . However, it should alert the examiner to the possibility of developing microcephaly. (See "Microcephaly in infants and children: Etiology and evaluation".)
Other causes of early closure of the anterior fontanelle include [6,7]:
•Hypophosphatasia (see "Periodontal disease in children: Associated systemic conditions", section on 'Hypophosphatasia')
•Hyperparathyroidism (see "Primary hyperparathyroidism: Clinical manifestations")
The approach to the child with early closure of the anterior fontanelle depends upon associated clinical findings. As examples:
•Ridging at the suture lines suggests craniosynostosis (see "Overview of craniosynostosis")
•Decreased head circumference (or decreasing percentile) indicates microcephaly (see "Microcephaly in infants and children: Etiology and evaluation")
●Delayed closure – The most common causes of delayed closure of the anterior fontanelle include [5,7,8]:
•Congenital hypothyroidism (see "Clinical features and detection of congenital hypothyroidism")
•Primary megalencephaly (see "Macrocephaly in infants and children: Etiology and evaluation", section on 'Increased brain parenchyma')
•Increased intracranial pressure (see "Idiopathic intracranial hypertension (pseudotumor cerebri): Clinical features and diagnosis" and "Elevated intracranial pressure (ICP) in children: Clinical manifestations and diagnosis")
•Down syndrome (see "Down syndrome: Clinical features and diagnosis")
•Rickets (see "Overview of rickets in children")
Other causes of delayed closure of the anterior fontanelle are listed in the table (table 1). Many of these disorders are associated with an enlarged anterior fontanelle and dysmorphic features that help to make the diagnosis.
Third fontanelle — The "third fontanelle" is not really a fontanelle but a bony defect approximately 2 cm (1 inch) anterior to the posterior fontanelle along the sagittal suture [9,10]. It is thought to be due to incomplete ossification of the parietal bones . In a cross-sectional study of the sagittal suture, no infants older than 90 days had a palpable third fontanelle .
In studies of consecutive newborn infants, 2 to 6 percent have a palpable third fontanelle [9,11]. In the largest study, which included 966 full-term and 54 preterm infants, 6.3 percent had a third fontanelle . The diameter of the third fontanelle ranged from 7 to 35 mm (0.3 to 1.4 inches); approximately one-third of the third fontanelles were ≥13 mm (0.5 inches). None of the infants in this study had associated major congenital malformations or congenital infections. However, given that a third fontanelle has been reported in children with Down syndrome, congenital infections (syphilis and rubella), and hip dislocation, some authors consider it to be a potential sign of these disorders [10,11].
Forehead — Palpate the forehead to assess for frontal bossing and midline ridging. Midline ridging of the forehead may be associated with trigonocephaly and metopic synostosis (figure 1). Frontal bossing may be associated with skeletal dysplasia, a genetic syndrome, underlying brain abnormalities, and hematological causes, amongst other etiologies .
Parietal area — Palpation of the parietal area of the skull, particularly in a premature infant, may elicit an unusual, spring-like, bony compressibility (craniotabes), similar to the sensation of pushing in the side of a ping-pong ball. Persistent craniotabes in children older than six to nine months may be an indication of several disorders, including syphilis and rickets [3,14].
Auscultation — An audible cranial bruit in a child during the first several years of life may be a normal finding. Systolic bruits assume more significance as the child gets older. A transmitted cardiac murmur may give rise to an audible cranial bruit, eliminated readily by gentle pressure over the ipsilateral carotid artery. A continuous bruit with systolic accentuation that is not eliminated by gentle pressure over the ipsilateral carotid artery may indicate an intracranial arteriovenous malformation.
Transillumination — Transillumination of the skull may be performed in children younger than one year. Intracranial defects, such as hydranencephaly and hydrocephalus, can be transilluminated with a Chun gun or flashlight fitted circumferentially with a rubber or sponge cup. Unlike the skull of the normal child, that of the patient with either of these defects or anencephaly permits light to be transmitted far beyond the circumferential rim of the instrument being used. The results should be confirmed with neuroimaging (eg, ultrasonography of the head).
Scalp and hair — The texture, pattern, and amount of scalp hair may suggest an underlying problem.
●Dry, scaling areas of the scalp can be caused by psoriasis or seborrheic dermatitis (picture 4). (See "Cradle cap and seborrheic dermatitis in infants", section on 'Clinical manifestations' and "Psoriasis: Epidemiology, clinical manifestations, and diagnosis", section on 'Chronic plaque psoriasis'.)
●A bald spot over the occipital area frequently is found in infants placed in the supine position for sleeping and in developmentally delayed children who fail to change head position.
●A white forelock, associated with congenital deafness, may be found in patients with Waardenburg syndrome . The major features of Waardenburg syndrome are lateral displacement of medial canthi (dystopia canthorum), partial albinism, and deafness (picture 5) . (See "The genodermatoses: An overview", section on 'Waardenburg syndrome'.)
●Twisted, short, fragile hair can be associated with Menkes disease, a genetic disorder mediated by copper deficiency (picture 6) . The other major features of Menkes disease are progressive cerebral deterioration, seizures, twisted and fractured hair, and metaphyseal widening of bones (particularly ribs and femur) . (See "Overview of dietary trace elements", section on 'Menkes disease'.)
●Coarse, dry hair is found in patients with hypothyroidism. (See "Acquired hypothyroidism in childhood and adolescence".)
●Patches of alopecia may occur at the previous site of a scalp probe or intravenous insertion and in patients with:
•Tinea capitis (picture 7A) (see "Tinea capitis", section on 'Clinical manifestations')
•Trichotillomania (picture 7B) (see "Skin picking (excoriation) disorder and related disorders", section on 'Trichotillomania')
•Ectodermal dysplasia (picture 7C) (see "The genodermatoses: An overview", section on 'Ectodermal dysplasias')
•Alopecia areata (picture 7D) (see "Alopecia areata: Clinical manifestations and diagnosis")
●Dysmorphic features – The clinician should pay close attention to the patient's anatomic facial structures, including the:
•Size of the mouth
•Shape of the lips
•Length and appearance of the philtrum
•Size and shape of the nose
•Distance between the eyes
•Width of the palpebral fissures
•Size, shape, and position of the auricle
Atypical facial features may reveal a phenotypic pattern compatible with a particular syndrome attributable to maternal drug or alcohol ingestion (picture 9) or to a specific genetic or chromosomal abnormality. Select conditions associated with genetic or chromosomal abnormalities are discussed separately. (See "Detailed neurologic assessment of infants and children", section on 'Dysmorphic features'.)
●Facial edema – Periorbital or facial edema can occur as part of a systemic allergic reaction, infectious mononucleosis (periorbital edema), or may be the first indication of nephrotic syndrome. Unilateral orbital or facial edema can occur as a result of an insect bite or cellulitis. (See "Anaphylaxis: Acute diagnosis", section on 'Symptoms and signs' and "Clinical manifestations, diagnosis, and evaluation of nephrotic syndrome in children", section on 'Clinical manifestations'.)
●Soft tissue swelling – Unilateral or bilateral facial swelling not caused by edema may be secondary to an infectious process (eg, parotid gland swelling in mumps (picture 10)). Lymphadenopathy, lymphadenitis (picture 11), and salivary gland pathology cause submandibular soft tissue swelling. (See "Mumps", section on 'Clinical manifestations' and "Cervical lymphadenitis in children: Etiology and clinical manifestations".)
●Muscle tone – Unilateral facial paralysis secondary to a peripheral or central facial nerve defect may be attributable to a traumatic injury, viral or bacterial infection, or other abnormality. (See "Facial nerve palsy in children".)
Tense, rigid facial muscles are seen in patients with hypocalcemia, tetanus, and other infections. (See "Clinical manifestations of hypocalcemia", section on 'Acute manifestations' and "Tetanus".)
EYES — Patient cooperation is essential to a good eye examination. Infants and younger children are best examined held upright in the arms of their caregivers, with their attention drawn to a toy or bright object. Infants tend to be easier to examine than toddlers and preschool children. By age six to eight years, children usually are able to sit alone facing the examiner to follow directions. The eye examination of newborn infants and eye injuries are discussed separately. (See "Overview of eye injuries in the emergency department" and "Approach to diagnosis and initial treatment of eye injuries in the emergency department".)
Appearance — Before using the ophthalmoscope or touching the child, the examiner should note the position and spacing of the eyes, width of palpebral fissures, eye color, appearance of the sclera and conjunctiva, condition of the eyelids, pupillary size and reaction to light, and eye movement. Asymmetry of the eyes may be the result of prominent epicanthal folds (picture 12), a difference in the size of the globes (picture 13), or ptosis (picture 14C). Long or short palpebral fissures are the norm for some patients but can be part of a syndrome complex in others (eg, short palpebral fissures in fetal alcohol spectrum disorders).
●Eyelids – Examination of eyelids should include the lashes, color, presence of ptosis, and skin defects.
•Lid discoloration – Erythematous or violaceous eyelids may be the result of hemangiomas or vascular malformations (picture 14A), or they can appear secondary to trauma, infection, metastasis, or connective tissue disorders (eg, dermatomyositis (picture 14B)).
•Creases – Small linear creases involving the lower eyelid (Dennie lines or Morgan folds) occur in patients with allergies .
•Edema – Edematous eyelids may occur in infectious mononucleosis or be the result of hypoproteinemia as part of the nephrotic syndrome. (See "Clinical manifestations and treatment of Epstein-Barr virus infection", section on 'Acute infectious mononucleosis' and "Clinical manifestations, diagnosis, and evaluation of nephrotic syndrome in children", section on 'Clinical manifestations'.)
•Ptosis – A mild degree of unilateral or bilateral congenital ptosis, often of undetermined cause, is common. Acquired causes of ptosis include myasthenia gravis, third cranial nerve palsy (picture 14C), and ophthalmoplegic migraine. (See "Third cranial nerve (oculomotor nerve) palsy in children".)
-Flaking, erythema, and mild swelling of the eyelid margins are seen in patients with blepharitis (picture 14D), which often is attributable to seborrheic dermatitis of the scalp or face. (See "Blepharitis".)
-A stye (external hordeolum) presents as painful inflammation of the hair follicles or accessory glands along the lid margin (picture 14E), usually caused by Staphylococcus aureus infection. (See "Eyelid lesions", section on 'Hordeolum (stye)'.)
●Discharge – Eye discharge or excessive tearing from one or both eyes may indicate a pathologic condition:
•Purulent discharge can occur as a result of bacterial infection (eg, Neisseria gonorrhea (picture 15)) or chemical irritant (eg, silver nitrate). (See "Conjunctivitis" and "Gonococcal infection in the newborn", section on 'Ophthalmia neonatorum'.)
•Abundant tearing may result from a blocked tear duct, foreign body, allergic reaction, infection, or glaucoma. (See "Approach to the child with persistent tearing", section on 'Etiology of persistent tearing'.)
•Inflammation of the conjunctivae (conjunctivitis) may be caused by an infectious process, irritants, toxins, crying, or systemic disorders (eg, Kawasaki disease (picture 16)). (See "Conjunctivitis".)
•Subconjunctival hemorrhages caused by injury or inflammation generally are benign and self-limiting (picture 17).
•Focal lesions – Epithelial hyperplasia that gives rise to a mildly uncomfortable yellow-white lesion involving the bulbar conjunctiva (pinguecula) (picture 18) should be differentiated from a pterygium (picture 19), a painless lesion of similar appearance that may grow over the cornea . (See "Pterygium".)
Extraocular movement — A penlight, finger, or other object should be used to assess extraocular muscle movement. Symmetric movement of the eyes should occur as the patient's eyes follow the finger or object, tracking it superiorly, inferiorly, laterally, medially, and obliquely. Nystagmus should be noted. (See "Detailed neurologic assessment of infants and children", section on 'III (oculomotor), IV (trochlear), and VI (abducens)'.)
Ocular alignment — The corneal light reflex is tested to determine eye alignment. When a light source is held directly in front of a patient who is staring straight ahead, normal eye alignment will reveal a symmetric reflex in the center of each pupil (figure 3A). If the light reflex in one eye is inwardly displaced, that eye is exotropic; if outwardly displaced, it is esotropic; and if inferiorly displaced, it is hypertropic .
The cover-uncover eye test is a more accurate test for ocular alignment in the cooperative patient. Testing is done with the patient looking first at a near object and then at a far object. As the patient fixates on the object, one eye is rapidly covered with a hand or occluder and the other eye is observed for movement (figure 3B). Normally, neither eye should move as they are alternately tested.
Intermittent strabismic gaze, a misalignment of the eyes, may be normal during the first several months of life. Children with constant eye deviations (at any age) or intermittent deviations that persist after four months of age should be referred to an ophthalmologist for further evaluation. Many factors, including eye muscle weakness, cranial nerve abnormalities, cataract, chorioretinitis, and retinoblastoma can interfere with the normal visual axis. In young infants and children, large epicanthal folds may cause the illusion of strabismus (pseudostrabismus). (See "Evaluation and management of strabismus in children", section on 'Causes' and "Evaluation and management of strabismus in children", section on 'Indications for referral'.)
●Vision/visual acuity – Assessment of vision/visual acuity in infants and children (table 2) is discussed separately. (See "Vision screening and assessment in infants and children", section on 'Visual acuity'.)
●Visual field assessment – Visual field assessment can be conducted in the child old enough to cooperate by having the child sit opposite the examiner at a distance of only a few feet and telling them to look at a particular part of the examiner's face (eg, the nose). With both arms fully extended in opposite directions, the examiner begins wiggling a toy or the fingers of one hand and asks the patient to indicate (verbally or by pointing) when the movement comes into the child's visual field. Assuming the examiner has normal visual fields, assessment of any significant loss or deficiency in the patient can be determined. All four visual field quadrants should be tested. For the older patient, the examiner may choose to perform the test by holding up a certain number of fingers and having the patient identify them when they come into range.
●Red reflex – Examination of the red reflex is useful in the detection of several eye conditions, including cataracts, corneal foreign body or abrasion, strabismus, and retinoblastoma (figure 4). Examination of the red reflex should be performed in a darkened room. Ophthalmoscopic examination of the eyes should begin at a distance with the beam of light (largest diameter) projected onto the upper facial area. The lens setting should be adjusted to bring the skin around the child's eyes into focus. From a distance of approximately 46 cm (18 inches), the fundi are visualized individually and simultaneously (Bruckner test). Viewing the retina obliquely, in addition to straight-on, may improve the detection of retinoblastoma . In more darkly pigmented individuals, the reflex may be more gray than red .
Occasionally, visualization of the red reflex through the ophthalmoscope is difficult, particularly in young children, who may cry, turn away from the examiner, or shut their eyes as the examiner approaches. Better visualization may be achieved with the handheld otoscope from a distance of several feet. The magnifying lens of the otoscope is moved to the side, out of the examiner's field of vision. While the examiner looks through the aperture, the beam of light can be directed onto each eye separately or onto both eyes simultaneously.
Any opacity involving anatomic structures through which the light must pass will create a dull or abnormal color ; mucus in the tear film, a transient opacity, disappears after the child blinks. Children who have an abnormal red reflex (eg, dark spots, markedly diminished reflex, white reflex, asymmetry) should be referred to an ophthalmologist experienced in the examination of children (figure 4). (See "Approach to the child with leukocoria", section on 'Referral'.)
●Cornea – Examination of the cornea should reveal a clear transparent membrane. Adequate visualization requires use of an ophthalmoscope set at +8 to +6 diopters. Any corneal opacity, including that owing to haziness or ulceration, is abnormal.
Ulcerations may appear as a result of infection, foreign body, connective tissue disease, or trauma (picture 22). Traumatic lacerations and acute ulcerations are extremely painful and are accompanied by photophobia, conjunctivitis, and pupillary constriction. (See "Corneal abrasions and corneal foreign bodies: Clinical manifestations and diagnosis".)
●Anterior chamber – After visualization of the cornea, the anterior chamber should be examined with the ophthalmoscopic lens set at approximately +6 diopters. It should be completely free of opacities. Blood in the anterior chamber is a result of trauma (picture 23). Turbidity and cellular debris in the chamber are caused by inflammation of the iris and ciliary muscle secondary to an autoimmune reaction. (See "Traumatic hyphema: Clinical features and diagnosis".)
●Iris and lens – The ophthalmoscopic setting should be +4 to +2 diopters to examine the iris and lens. Cataracts, noted as a white pupillary reflex (leukocoria), can be seen without use of an ophthalmoscope. Cataracts appear white or gray in a well-lit room or in natural sunlight (picture 24); through the ophthalmoscope, they are dark or almost black. (See "Cataract in children", section on 'Clinical features'.)
Cataracts can be congenital or acquired as the result of infection, metabolic disease, drugs, toxins, traumatic injury, glaucoma, or retinoblastoma. Certain dermatologic abnormalities and several musculoskeletal, central nervous system, and craniofacial syndromes also are associated with cataracts. (See "Cataract in children", section on 'Etiology'.)
Visual impairment generally develops with cataracts. If the cataract remains small, however, no visual difficulty may occur.
●Retina and optic disk – Examination of the retina and optic disk requires ophthalmoscopic lens settings of 0 to -2 diopters. When close to the patient, the examiner can clearly visualize the optic disk, blood vessels, and, more laterally, the macula. The fundus should be pink to red (picture 25), although in anemic patients and in darkly pigmented individuals it may be gray-white. If an almost completely white and somewhat opaque light reflex is noted, impairing the examiner's ability to identify the optic disk, blood vessels, and macula, the patient may have a cloudy cornea, lens opacity, retinoblastoma, retinopathy of prematurity, or retinal detachment. (See "Approach to the child with leukocoria", section on 'Causes of leukocoria'.)
Appearance — The examiner should note the relationship of the ears to the rest of the face and the shape and position of the auricles (figure 5).
●Position of the auricle – The ears are considered low set if the superior rim of the auricle is below a line drawn posteriorly from the superior orbital rim or if the superior insertion of the ear to the scalp is below an imaginary line drawn from the inner canthus . Low-set ears are associated with a number of syndromes, including Potter sequence, Noonan syndrome, Treacher Collins syndrome, and trisomy 18. (See "Detailed neurologic assessment of infants and children", section on 'Dysmorphic features'.)
Protruding, anteriorly placed auricle can be a normal anatomical variant (picture 26A). If the external ear is displaced outward and anteriorly, consideration should be given to a diagnosis of mastoiditis (picture 26B), external otitis (picture 26C), or cellulitis (picture 26D), among others. (See "Acute mastoiditis in children: Clinical features and diagnosis", section on 'Clinical features' and "External otitis: Pathogenesis, clinical features, and diagnosis".)
●Malformed auricle – Malformation of the auricle may occur in syndromes that affect mandibulofacial structures (eg, Treacher Collins or Goldenhar syndrome). (See "Syndromes with craniofacial abnormalities".)
●Skin tags and pits – Preauricular skin tags occasionally are associated with hearing loss but generally have no clinical significance. Preauricular skin pits (picture 27A-B) are also unlikely to be associated with hearing loss, except in the branchiootorenal syndrome  . A preauricular pit infrequently may extend into a subcutaneous cyst and become infected. The cellulitis needs to be treated promptly with antibiotics to prevent perichondritis. (See "Congenital anomalies of the ear", section on 'Preauricular pits' and "Congenital anomalies of the ear", section on 'Accessory auricular appendage/preauricular tag'.)
Palpation — Palpation of the tragus or auricle may elicit significant pain in the patient with external auditory canal irritation. The canal can become swollen, erythematous, and painful as a result of a foreign body, external otitis (picture 26C), insect bite, or furuncle. In these situations, discomfort and swelling may become so significant that visualization of the tympanic membrane becomes difficult. (See "External otitis: Pathogenesis, clinical features, and diagnosis".)
Calcification or ossification of the auricular cartilage ("petrified ear") occurs infrequently. It is characterized by the development of hardened auricular cartilage without changes in the appearance of the ear [26,27]. The earlobe is spared [26,27]. Some patients may have pain with pressure, but most are asymptomatic. Auricular calcification may be related to increased levels of calcium and phosphorous or occur after injury or inflammation of the cartilage (eg, cold injury, frostbite, mechanical trauma, radiation therapy) [26,27]. Associated systemic conditions include endocrine disorders (diabetes mellitus, adrenal insufficiency, hypopituitarism, hypothyroidism, acromegaly), sarcoidosis, ochronosis, and familial cold hypersensitivity. Laboratory evaluation of patients with calcification of the auricular cartilage should be guided by other clinical findings . Extensive evaluation usually is not necessary.
●Equipment and preparation – The clinician should have an appropriate otoscope containing a strong light source (preferably a halogen light) to complete the ear examination. The diameter of the external auditory canal varies considerably among children; a range of specula should be available.
The examiner may need to clear the canal of excessive cerumen and foreign material in order to see the entire canal and tympanic membrane. Cerumen removal and removal of foreign bodies in the ear are discussed separately. (See "Cerumen", section on 'Cerumen removal' and "Foreign bodies of the outer ear (pinna [auricle] and external auditory canal): Diagnosis and management".)
Visualization is best achieved with the patient sitting in an upright position or lying supine with the head appropriately tilted. Other positions that can be used for an uncooperative child include:
•Having the caregiver holding the child firmly on their lap, with the child's legs between their own legs. The child's head should be turned to the side and securely braced against the caregiver's shoulder or chest, with the caregiver securing the child's hands with one hand and the child's head with the other hand.
•Placing the child in the supine position with the arms extended, the elbows firmly pinioned at the sides of the head, and the extended legs gently immobilized by the weight of the accompanying adult's body lying over the thighs, knees, and lower legs.
The examiner should insert the otoscopic speculum into the external auditory canal as gently as possible. If the examiner is right-handed, the ulnar aspect of the right hand holding the instrument is comfortably braced against the right side of the patient's face or forehead to steady the position of the instrument. At the same time, the thumb and index finger of the opposite hand are used to pull the auricle superiorly and posteriorly, allowing maximal visualization of the external auditory canal.
There are two options for examining the other ear. The examiner can brace the ulnar aspect of their dominant hand behind the auricle at the level of the mastoid bone. At the same time, the thumb and index finger of the nondominant hand are positioned so that they can pull the auricle superiorly and posteriorly. Alternatively, the examiner positions their hands the same way to examine both ears, using their nondominant hand to hold the otoscope and their dominant hand to position the pinna of the other ear.
Other devices such as digital otoscopes are available to help the medical team visualize ear examination findings easily with the use of a display screen. They can use these images to explain ear examination findings to patient families. These devices avoid repeated ear examination of different team members in an uncooperative child, who may dislike repeated ear examinations .
•External auditory canal – The external auditory canal normally is smooth and pink; it is short and straight in the infant and younger child, and somewhat longer and more angulated in the older patient.
•Tympanic membranes – Tympanic membranes generally are translucent (picture 28A), occasionally allowing for visualization of several middle ear structures (umbo, manubrium of the malleus, round window niche, pars flaccida, and chorda tympani nerve) (figure 6). The normal tympanic membrane varies slightly in color and appearance.
Middle ear function is evaluated by assessing the degree of mobility of the tympanic membrane using pneumatic otoscopy or tympanometry. Both techniques require a tight seal between the speculum or rubber ear piece and the external auditory canal. Movement is best visualized in the posterosuperior quadrant of the tympanic membrane.
The tympanic membrane normally moves inward with slight positive pressure and outward with slight negative pressure (movie 1). Significant negative pressure in the middle ear is noted when applied positive pressure produces no movement and negative pressure results in exaggerated movement. Negative pressure in the middle ear is caused by a thick, tenacious middle ear effusion. A bulging tympanic membrane caused by excessive middle ear effusion with little to no visible air will exhibit nearly complete or total absence of mobility (movie 2) .
The otoscopic findings of acute otitis media and otitis media with effusion are described separately. (See "Otitis media with effusion (serous otitis media) in children: Clinical features and diagnosis", section on 'Clinical features' and "Acute otitis media in children: Clinical manifestations and diagnosis", section on 'Otoscopic evaluation'.)
A perforated tympanic membrane in the absence of infection may be indicative of traumatic injury from a foreign body (picture 28B), increased barometric pressure, iatrogenic injury, or previous surgical incision for ventilating tubes (picture 28C).
Hearing — Hearing deficits may be congenital or idiopathic; may result from an infectious disease, a hereditary renal disorder, or a drug exposure; or may be a component of numerous syndromes. The problem can be conductive, neurosensory, or both. (See "Hearing loss in children: Etiology".)
Several techniques are available to assess hearing in infants and children. (See "Hearing loss in children: Screening and evaluation".)
●Newborns and infants
•Universal screening of newborns for hearing loss is recommended in the United States; newborns may be screened for hearing with auditory brainstem response or otoacoustic emissions. (See "Screening the newborn for hearing loss".)
●Infants and young children
•Gross hearing can be evaluated in infants and uncooperative young children by observing their physical response to sound; a startle response, eye blinking, and turning toward the sound are normal reactions.
•Various behavioral tests are available for more formal hearing testing in cooperative young children. (See "Hearing loss in children: Screening and evaluation", section on 'Tests for young and/or uncooperative children'.)
•In the older, more cooperative child, crude testing can be performed by standing close to the patient and mouthing relatively inaudible words into the child's ear or whispering words at a distance of one to two feet from one ear while occluding the external auditory canal of the opposite ear. The child then can be asked to repeat what was said.
•More formal testing can be done in cooperative older children with standardized audiometric testing; otoacoustic emissions testing or auditory brainstem responses can be used for uncooperative older children. (See "Hearing loss in children: Screening and evaluation", section on 'Formal audiology'.)
NOSE — Examination of the nose is conducted with the patient's head tilted back in a sniffing position and the clinician sitting directly opposite. The shape, size, and position of the nose should be noted. Inspection of internal structures is done using a bright light source and nasal speculum (figure 7) or, for the smaller child, an ear speculum. To reduce patient discomfort and steady the head, the examiner should position the outer ulnar aspect of the hand not holding an instrument against the patient's forehead; the thumb of that hand is used to elevate the tip of the nose. This procedure allows for optimal visualization of each vestibule, the nasal turbinates, septum, and mucosal surfaces.
Normally, the mucosal surfaces are pink, and the vestibules are patent and easily visible to the level of the middle turbinates (picture 29). The septum should be in the midline, although a slight deviation is acceptable. Transient septal deformity secondary to in utero positioning may be noted in the newborn. The differential diagnosis of septal perforation includes infectious diseases, inhaled drugs (particularly cocaine), and traumatic injury.
Swelling, bleeding, abnormal lesions, and types of secretions should be noted.
●Thin serous or watery nasal discharge may be seen in patients with allergic rhinitis or a viral upper respiratory tract infection (URI). (See "An overview of rhinitis".)
●An almost crystal-clear nasal discharge can occur with leaking cerebral spinal fluid. (See "An overview of rhinitis", section on 'Differential diagnosis'.)
●A more viscous nasal discharge may occur during the latter stages of a viral URI. (See "The common cold in children: Clinical features and diagnosis", section on 'Clinical features'.)
●Thick purulent nasal discharge is typical of a viral or bacterial infection involving the nasopharynx or sinuses. (See "Acute bacterial rhinosinusitis in children: Clinical features and diagnosis", section on 'Clinical features'.)
●An impacted foreign body should be suspected in the patient with unilateral, malodorous, purulent nasal discharge. (See "Diagnosis and management of intranasal foreign bodies".)
Nasal obstruction — If a newborn has an apparent nasal obstruction, the examiner should rule out the possibility of choanal atresia by attempting to pass a small-gauge feeding tube or French catheter through each nasal passageway. (See "Congenital anomalies of the nose", section on 'Choanal atresia'.)
Occluded nasal passageways caused by boggy nasal mucosa may develop as a result of allergies, vasomotor rhinitis, or overuse of nasal decongestants. (See "An overview of rhinitis".)
Nasal polyps (picture 30) caused by allergies or associated with cystic fibrosis may cause unilateral or bilateral nasal obstruction. (See "Chronic rhinosinusitis: Clinical manifestations, pathophysiology, and diagnosis" and "Cystic fibrosis: Clinical manifestations and diagnosis", section on 'Sinus and nasopharyngeal disease'.)
Adenoidal hypertrophy — Adenoidal enlargement can obstruct the nasopharynx, making nasal breathing difficult and creating the typical open-mouth adenoid facies (figure 8). (See "Etiologies of nasal obstruction: An overview".)
Although estimates of adenoidal size on lateral skull radiographs have been reported to correlate with adenoidal weight at surgery  and with a clinical score of adenoidal symptoms , there is no evidence that such analysis is clinically useful. Evaluation of adenoidal hypertrophy is best made on clinical grounds and by direct visualization of the adenoids by the otolaryngologist. Radiographs contribute little to the care of children with suspected adenoidal hypertrophy.
MOUTH AND THROAT
Inspection — Examination of the mouth begins with visual inspection of the lips for color, texture, and anatomic defects. The width of the vermilion border and the shape and size of the orifice should be noted. Abnormal findings may be compatible with multisystem disorders, such as Williams syndrome (picture 31), or they can be caused by maternal substance abuse, as seen in the fetal alcohol syndrome.
Mouth examination includes the gingiva, teeth, buccal mucosa, salivary ducts, tongue, palate, tonsils, and uvula.
●Ulcerations of the lips, gingiva, and/or mucosal surfaces are compatible with herpetic stomatitis (picture 32), aphthous ulcers (picture 33), metabolic disorders, drug reactions, or secondary complications from underlying immunosuppressive disease. Extensive inflammation and erosion of surfaces may be the result of primary infection or poor oral hygiene with secondary infection.
●Obstructed salivary ducts can be caused by concretions, leading to the development of a cyst-like structure in the floor of the mouth (ranula) (picture 34), or by inflammation, leading to painful swelling in the area of the parotid gland. (See "Congenital anomalies of the jaw, mouth, oral cavity, and pharynx", section on 'Ranulas'.)
●Fissuring or cracking of the tongue may be a normal variant but also occurs with poor hydration and vitamin deficiency. Geographic tongue (benign migratory glossitis) is a chronic, recurring disorder characterized by pink to red, slightly depressed lesions with irregular, elevated, white or yellow borders (picture 35). (See "Soft tissue lesions of the oral cavity in children", section on 'Lesions of the tongue'.)
●Defects in the hard and/or soft palate, particularly midline cleft palate defects, should be noted. Dimpling of the soft palate and/or a bifid uvula may occur with a submucosal cleft.
Teeth — The development and continued good health of dentition in childhood is extremely important. Deciduous tooth eruption generally begins around six months of age with the appearance of the lower central incisors, followed over the next 18 months by the eruption of upper central incisors, lateral incisors, canines, and molars (figure 9). The majority of toddlers have the full complement of 20 teeth by age two. Misshapen or absent teeth, white or brown spots, caries, chipped or missing teeth, or significant delay in the development of primary teeth may occur in patients with underlying metabolic disorders, infectious diseases, or various syndromes. (See "Anatomy and development of the teeth" and "Developmental defects of the teeth".)
Tonsils — Visualization of the palatine tonsils generally is not possible until the child is six to nine months old. Once fully developed, the tonsils remain enlarged throughout childhood.
●Tonsil size – Tonsil size can be described by their relation to the lateral dimension of the oropharynx (figure 10). Removal is not necessary unless they become a nidus of significant recurrent infection or are enlarged enough to obstruct normal breathing. (See "Tonsillectomy and/or adenoidectomy in children: Indications and contraindications", section on 'Indications'.)
Enlarged tonsils with exudate may be caused by bacterial infection of the throat and tonsils with group A beta-hemolytic Streptococcus and other infectious agents (eg, diphtheria, Epstein-Barr virus).
●Tonsillar crypts – Tonsillar crypts can harbor bacteria. Calcified concretions of bacteria, mucus, and other debris may form within the crypts and are called tonsilloliths. Tonsilloliths may have a foul smell and can contribute to bad breath.
●Tonsillar asymmetry – Tonsillar asymmetry or unilateral tonsillar enlargement may be caused by infection, chronic inflammatory process, or neoplasm (particularly lymphoma). In addition, symmetric tonsils may appear to be asymmetric because of differences in the depth of the tonsillar fossa or asymmetric effacement of the tonsils by the tonsillar pillars [32-36].
Infectious causes of tonsillar asymmetry include peritonsillar cellulitis or tonsillar abscess (picture 36). Associated clinical features include severe sore throat, fever, a muffled voice, drooling, trismus, and/or neck pain. (See "Peritonsillar cellulitis and abscess".)
Tonsillar asymmetry in the absence of acute infection is concerning for a neoplastic process, particularly lymphoma [36-40]. However, in otherwise healthy and asymptomatic children with tonsillar asymmetry, the risk of malignancy is very low [32-35,41-43].
Clinical features suggestive of lymphoma in children with unilateral tonsil enlargement include rapid and progressive enlargement, systemic symptoms (eg, persistent fevers, weight loss, night sweats), significant ipsilateral cervical lymphadenopathy (>3 cm), and hepatosplenomegaly [32,34,39-41]. Other features that increase the concern for lymphoma include immunodeficiency, previous malignancy, unilateral tonsillitis unresponsive to medical therapy, and rapid bilateral tonsillar enlargement . (See "Overview of common presenting signs and symptoms of childhood cancer".)
Tonsillectomy is indicated in children with tonsillar asymmetry and features suggestive of malignancy [35,38,43]. However, a period of watchful waiting before surgical intervention is appropriate for asymptomatic children without acute infection [33,41,43]. (See "Tonsillectomy and/or adenoidectomy in children: Indications and contraindications".)
Pharynx — Examination of the pharynx usually requires visualization only. Pharyngitis is suggested by erythema and/or pharyngeal adenopathy (cobblestoning). It can be caused by viral, bacterial, or fungal disease; by a chemical irritant; or by a complication of some other condition. Soft tissue lesions and foreign body injuries should be noted.
NECK — Examination of the neck is best accomplished with the patient sitting or standing. The head should be in the midline position, comfortably held in extension.
●Neck appearance – The size and position of anatomic neck structures should be noted.
•A webbed-shape neck may be associated with Turner syndrome. (See "Clinical manifestations and diagnosis of Turner syndrome".)
•Redundant posterior neck folds can be seen in patients with Down syndrome. (See "Down syndrome: Clinical features and diagnosis".)
•A short neck with a low hairline and limited range of motion may be the result of bony anomalies of the cervical spine associated with Klippel-Feil syndrome (a congenital anomaly characterized by a defect in the formation or segmentation of the cervical vertebrae, resulting in a fused appearance); these patients frequently have accompanying genitourinary abnormalities.
•A short neck also occurs with congenital hypothyroidism and in some of the mucopolysaccharidoses (eg, Hurler and Morquio syndromes). (See "Clinical features and detection of congenital hypothyroidism" and "Mucopolysaccharidoses: Clinical features and diagnosis".)
●Neck veins – Distended or pulsating neck veins may indicate obstruction of blood return to the right heart (eg, mediastinal masses) or impaired cardiac function (eg, pericarditis or poor myocardial contractility). Distended pulsating carotid arteries normally are seen in patients who are emotionally upset and after vigorous exercise; if the finding persists, however, disorders such as aortic insufficiency, patent ductus arteriosus, hypertension, and severe anemia must be considered .
●Head tilt – A head tilt can result from several different conditions. In the infant, torticollis may be the result of sternocleidomastoid muscle fibrosis secondary to in utero pressure or trauma during delivery, myopathy, denervation, or venous occlusion . Head tilt also may occur in patients with extraocular muscle dysfunction (picture 37) and in those with a posterior fossa tumor or neuroblastoma. Patients with severe gastroesophageal reflux may exhibit a head tilt as a compensatory maneuver to help reduce the discomfort of reflux esophagitis (Sandifer syndrome) . (See "Congenital muscular torticollis: Clinical features and diagnosis" and "Acquired torticollis in children" and "Fourth cranial nerve (trochlear nerve) palsy", section on 'Clinical manifestations' and "Gastroesophageal reflux in infants", section on 'Reflux and irritability' and "Congenital muscular torticollis: Management and prognosis".)
●Palpation of the thyroid gland – Below the thyroid cartilage, the thyroid gland separates into two symmetric lobes and curves posteriorly around the sides of the trachea and esophagus (figure 11). Palpation of the thyroid is accomplished best with the examiner positioned behind the standing or sitting patient. The fingers of the examiner's hands are gently positioned over the respective lobes, which are normally soft, smooth, and not enlarged. The thyroid gland moves upward when the patient swallows. With repetitive palpation of the thyroid of many patients, the examiner will develop the feel of the normal range of size, shape, and contour.
•Midline neck masses – A soft tissue, freely movable, cystic mass in the midline of the neck superior to the upper border of the thyroid cartilage is most compatible with a thyroglossal duct cyst. Other midline lesions of the neck include sebaceous (epidermal) cysts, small abscesses, lipomas, and dermoids. (See "Thyroglossal duct cyst, thyroglossal duct cyst cancer, and ectopic thyroid".)
•Lateral neck masses – Abnormal lateral neck masses include :
-Enlarged lymph nodes in the cervical chain; causes of cervical lymphadenopathy (table 3) and lymphadenitis (table 4) are discussed separately (see "Cervical lymphadenitis in children: Etiology and clinical manifestations")
-Fibrosis or benign or malignant tumors of the sternocleidomastoid muscle (see "Congenital muscular torticollis: Clinical features and diagnosis", section on 'Physical examination')
-Branchial cleft cysts (soft, smooth masses palpable in the upper portion of the neck) (see "Differential diagnosis of a neck mass", section on 'Branchial cleft cyst')
-Cystic hygromas or lymphangiomas, which transilluminate easily and are not tender (see "Cervical lymphadenitis in children: Etiology and clinical manifestations", section on 'Other causes of neck swelling')
-Dermoid cysts (see "Differential diagnosis of a neck mass", section on 'Dermoid cyst')
●Head and face – Examination of the head includes assessment of head shape (figure 1), distribution of hair (picture 7A-D), scalp defects, abnormal lesions or protuberances (picture 1 and picture 2), lacerations, abrasions or contusions, head circumference, and fontanelles. (See 'Head' above.)
Examination of the face includes assessment of the anatomic structures (eg, the size, shape and position of the eyes, ears, nose, and mouth), periorbital or facial edema or swelling, musculature, and facial nerve function. (See 'Face' above.)
●Eyes – Examination of the eyes includes assessment of appearance (picture 13), eyelids (picture 14A-F), discharge (picture 15), extraocular movements, ocular alignment (figure 3A-B), vision (table 2), corneal light reflection (figure 3B), red reflex (figure 4), and ophthalmoscopic examination. (See 'Eyes' above.)
●Ears – Examination of the ears includes assessment of the shape, size, and position of the pinnae (auricles) (picture 26A-D), preauricular skin tags or pits (picture 27A-B), external ear canal, tympanic membrane (picture 28A-C), and hearing. (See 'Ears' above.)
●Nose and mouth – Examination of the nose includes assessment of the shape, size and position; inspection of the internal structures (picture 29 and picture 30); and assessment of nasal discharge or obstruction. (See 'Nose' above.)
Examination of the mouth includes inspection of the lips (picture 32), gingiva, teeth, buccal mucosa (picture 33), salivary ducts, tongue, palate, pharynx, tonsils (picture 36), and uvula. (See 'Mouth and throat' above.)
●Neck – Examination of the neck includes assessment of the size and position of the anatomic structures, neck vessels, head tilt (picture 37), masses or enlarged lymph nodes (picture 11), and palpation of the thyroid gland. (See 'Neck' above.)
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