Miscellaneous: How to conduct an extra oral examination

Extraoral Examination:
Assess the face for symmetry and any notable asymmetries.
Observe the head and neck region for symmetry and abnormalities.
Check for facial asymmetry due to factors like bone issues, soft tissue problems, or previous surgeries or injuries.

Examination of the Eye:
Inspect the patient’s eyes for potential systemic conditions.
Look for signs such as Corneal arcus or xanthelasma, which may indicate dyslipidemia and increased cardiovascular disease risk.
Be alert to proptosis (bulging eyes), which can suggest endocrine disorders like Graves’ disease or even malignancy.
Recognise that acute proptosis following facial injury may indicate a retrobulbar haemorrhage, requiring immediate referral.

Examination of the Neck:
Inspection of the Neck:
– Start with visual inspection and identify any neck scars from prior surgeries (e.g. thyroidectomy, tracheostomy, neck dissection).
– Check for the presence of masses in the neck.
Key Features to Note for Lumps:
– Site, size, shape, surface, colour, consistency, compressibility, temperature, tenderness, transillumination, edge/margin, pulsatility, fixation.
– Assess the relationship to underlying or overlying tissues.
– Auscultation for bruits (e.g. carotid aneurysm).
Palpation of Cervical Lymph Nodes:
– Routine examination for palpable and tender lymphadenopathy.
– Note size, site, number, consistency, tenderness, and mobility of nodes.
– Assess for reasons behind lymphadenopathy, possible infections, and systemic issues, including malignancy.
– Inquire about risk factors like smoking and alcohol intake.
– Consider oral cancer risk if an adult presents with unilateral enlarged lymph nodes.
– Perform palpation with the patient seated in a relaxed and slightly flexed neck position.
– Palpate various lymph node groups: submental, submandibular, pre-auricular, post-auricular, occipital, cervical chain (upper, middle, lower), and supraclavicular.
Temporomandibular Joint (TMJ) Examination:
– Follow the LOOK, FEEL, and MOVE pattern.
– Look for redness or swelling over the TMJ.
– Gently press over the TMJ and assess for pain.
– Have the patient open and close their mouth while checking for clicks or crepitus.
– Note any deviation in mouth opening and the direction of deviation.
– Record limitations in mouth opening (normal range: 40-50mm, with 35mm considered acceptable).
– Assess protrusion and lateral excursions, comparing left and right sides.
– Palpate the masticatory muscles (masseters, temporalis, and lateral pterygoid) for tenderness and trigger points.
– Extraoral palpation of masseter provides information on superficial fibres, while intraoral palpation assesses the deep fibres.
– Assess for signs of parafunction, such as scalloping of the tongue, linear ablation on buccal mucosa, tooth substance wear, and potential tooth fractures.
Temporomandibular Disorder (TMD) characteristics:
– Tenderness on TMJ palpation.
– Joint sounds.
– Masticatory muscle tenderness.
– Deviation of the mandible.
– Signs of parafunction.