Part II Examination of the Newborn and Older Child
4 Examination of the Older Child
4.8 Examination of the Head, Face, and Neck
4.8.2 Face Examination
• Note any facial asymmetry or dysmorphic features.
• Look at the jaw size, excluding abnormalities such as micrognathia (an underdevel-oped jaw), which can be seen in many syndromes (e.g., Pierre Robin syndrome).
Eyes Examination
• External inspection
– Note the eyes’ shape, size, and orientation, and examine for photophobia.
– Inspect the eyebrow, eyelids, eyelashes, and the eyeballs, noting any gross abnormalities, such as sunken eyes, setting-sun eye phenomenon (hydroceph-alus or intracranial tumor), exophthalmos, strabismus, epicanthic folds (famil-ial or seen in Down syndrome), hyper- or hypotelorism, puffy eyelids, ptosis, excess tearing, or any other eye abnormalities.
– Retract the lower eyelids gently, inspecting the sclerae for jaundice or discoloration.
– Look at the conjunctivae for any redness, subconjunctival hemorrhages, swelling, discharge (as in Gonorrhea), or pallor.
– Examine the cornea and irises for any abnormalities, e.g., corneal opacities, megalocornea (in glaucoma).
– Note the pupils’ shape and size, as well as reaction to light.
– See whether the child is able to fixate, and note the presence of nystagmus.
– Examine for eye alignment:
Note the symmetry of corneal light reflex (see Fig. 4.9).
Perform the cover–uncover test to identify strabismus (see Fig. 4.10). This test should be performed while the child is looking at interesting near (33 cm) and distant (6 m) objects. A valid test requires good eye movement and vision. Cover one eye and watch the other. When the fixing eye is cov-ered, the squinting eye moves rapidly to fix on the object. If you remove the cover, the squinting eye moves away again. Repeat the same procedure on the other eye.
• Assess eye function
– Examine the direct and consensual pupillary reactions to light and the accom-modation reflex, noting the size and symmetry of the pupils.
– Eye movements (see Sect. 4.14.3.2).
– Visual field (see Sect. 4.14.3.2).
– Assess visual acuity by different methods, according to the child’s age (see Sect. 4.14.3.2).
– Conduct a color vision test using Ishihara color plates or Hardy Rand Littler.
• Fundoscopy
– Test for the red reflexes of both eyes. If it is absent or partly obscured (sug-gests a cataract or a retinoblastoma), perform formal fundoscopy at the end of the examination (see Sect. 4.14.3.2).
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Ear Examination
• Ask the parent to hold his/her child in the proper position (see Fig. 4.11).
• Inspect the shape, position, and size of the ears, and look for any abnormalities, like ear absence, nondevelopment of the auricle, and preauricular tags. Auricular malformations may be associated with renal anomalies.
• Normally, if a continuous horizontal imaginary line is drawn from the outer can-thus to the ear, it divides the ear into the upper one-third and lower two-thirds.
Passage of this line above the top of the pinna indicates low-set ears, which occur in Down syndrome, Turner syndrome, and mucopolysaccharidoses.
• Note the external auditory meatus to determine whether it looks normal or not, and look for any ear discharge.
• Palpate the external ear for any swelling or tenderness.
• Percuss the mastoid bone for tenderness.
• Test for hearing by observing the child’s responses to sound. Normally, he/she will turn his/her head toward the direction of the sound.
• Perform an otoscopic examination (see Box 4.5).
a
b
Fig. 4.9 Corneal light reflex test. Note the position of light reflection in the two eyes. (a) Symmetrical corneal light reflex (normal eyes). (b) Asymmetrical corneal light reflex (left conver-gent squint)
4 Examination of the Older Child
Nose Examination
• Note the shape and size of the nose, and inspect the nostrils, nasal mucosa, and septum, looking for any abnormalities (such as nasal flaring, nasal discharge, bleeding, swelling, polyp, or foreign body).
• Evaluate the patency of the nostrils: close one nostril with your figure, and note whether the child breathes easily, verifying the patency of the other nostril.
• Palpate sinuses for tenderness.
a
c b
Fig. 4.10 The cover–uncover test. (a) Left convergent squint. Note the asymmetrical corneal light reflex. (b) Covering of the fixing eye results in a rapid movement of the squinting eye to fix on the object. (c) If you remove the cover, the squinting eye moves away again
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Fig. 4.11 Method of holding a child’s head for ear examination. The child’s head is immobilized and the hands are kept out of the way. © Anwar Qais Saadoon
• The child must be positioned properly (see Fig. 4.11).
• When the child has pain in one ear, examine the other ear first.
• The largest speculum that can fit comfortably into the child’s meatus should be selected.
• The pinna must be gently pulled backward and downward (in infants and tod-dlers), or backward and upward (in older children), to make the external audi-tory canal straight.
• The otoscope should be held comfortably, and the ulnar border of your hand should be gently rested against the child’s cheek.
• The otoscope should be gently inserted up to 5 mm (in infants) or 1 cm (in older children), and the angle should be adjusted until visualization of the tympanic membrane is possible.
• Normally, the tympanic membrane appears pearly gray and translucent with a cone of light reflex on it. The absence of the cone of light reflex suggests inflammation.
• Look for any signs of ear infection (e.g., redness, bulging), and note any wax, foreign body, or tympanic membrane perforation.
Box 4.5: Otoscopy
4 Examination of the Older Child
Mouth and Throat Examination
• Ask the parent to hold the child properly (see Fig. 4.12).
• With the child’s mouth closed, inspect and palpate the lips, noting their color, symmetry, and condition, as well as any abnormalities (such as pallor, bluish- purple discoloration, cleft lips, fissures, or dryness).
• Inspect the mouth, using a tongue depressor and a penlight, looking at the following:
– Teeth: Color, number, arrangement, condition, and occlusion, noting any dental caries and loose or missing teeth
– Buccal mucosa: Color and condition, looking for any abnormalities (e.g., aphthous ulcers)
– Gum: Color and condition, noting any gum bleeding or hypertrophy
– Tongue: Size, symmetry, color, and dorsum surface, noting any large tongue (macroglossia), fissuring of the tongue (e.g., scrotal tongue in Down syn-drome), tongue tie, strawberry tongue (a swollen and bumpy tongue with large, red papillae can be seen with Kawasaki disease or scarlet fever), ulcers, or oral thrush (whitish discoloration of the tongue with an erythematous raw base, which is difficult to wipe away with the tongue depressor)
– Tonsils: Size, looking for any enlarged tonsils and noting any other abnor-malities (e.g., erythema, edema, and exudate).
– Palate: Inspect and palpate the hard palate to exclude any abnormalities (e.g., high arched or cleft palate), and note the movement of the uvula.
Fig. 4.12 Method of examination of the oral cavity by using a tongue depressor and a penlight.
© Anwar Qais Saadoon
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