Module 2
Module 2: Head, Eyes, Ears, Nose, Throat
Identify cranial findings, assess red reflex, and recognize oral cavity variations
Welcome to Module 2!
In this module, you’ll master the head, eyes, ears, nose, and throat examination in newborns. You’ll learn to differentiate benign birth trauma from concerning findings and develop confidence in performing critical examinations like the red reflex test.
Learning Objectives
By the end of this module, you will be able to:
- ✅ Differentiate caput succedaneum from cephalohematoma
- ✅ Assess fontanelles and sutures appropriately
- ✅ Perform red reflex examination and recognize concerning findings
- ✅ Identify benign oral findings (Epstein pearls) vs pathological conditions
- ✅ Recognize tongue-tie and its functional significance
- ✅ Understand when urgent referral is needed for HEENT findings
Lesson 1: Cranial Assessment
Birth-Related Head Findings
The newborn head undergoes significant forces during delivery, resulting in common findings that often alarm parents but are typically benign. Understanding these findings helps you provide appropriate reassurance.
Caput Succedaneum
Characteristics:
- Diffuse, edematous swelling of the scalp
- Crosses suture lines (key differentiating feature)
- Soft, pitting quality
- Present at birth
- May have overlying bruising or petechiae
Pathophysiology:
- Caused by pressure on the presenting part during labor
- Serosanguinous fluid accumulation in subcutaneous tissues
- More common with prolonged labor, vacuum assistance
Clinical Course:
- Resolves within 24-48 hours
- No treatment needed
- No long-term consequences
Parent Counseling: “This swelling is from pressure during delivery. It’s very common and will go away on its own in the next day or two. It doesn’t affect the brain or cause any problems.”
Cephalohematoma
Characteristics:
- Firm, fluctuant swelling
- Does NOT cross suture lines (confined by periosteum)
- Usually unilateral (most commonly parietal bone)
- Well-defined edges
- May not be apparent immediately at birth (develops over hours)
Pathophysiology:
- Subperiosteal hemorrhage
- More common with instrumental delivery (forceps, vacuum)
- Bleeding between skull bone and periosteum
Clinical Course:
- May increase in size over first 24-72 hours
- Takes weeks to months to resolve
- May calcify at edges (temporary ridge)
- Can contribute to hyperbilirubinemia as blood reabsorbs
Management:
- Monitor for jaundice
- No aspiration or intervention needed
- Reassurance to parents about slow resolution
Red Flags:
- Very large cephalohematoma (concern for skull fracture)
- Signs of increased intracranial pressure
- Severe jaundice
Parent Counseling: “This is a collection of blood just outside the skull bone from the delivery. It’s not on the brain. It will slowly go away over several weeks. We’ll watch for jaundice as it heals, but it doesn’t cause long-term problems.”
Molding
Characteristics:
- Temporary overlapping of skull bones
- Elongated or cone-shaped head
- Results from passage through birth canal
- More pronounced with prolonged labor
Clinical Course:
- Resolves within days
- Normal head shape returns as skull bones separate
Fontanelles Assessment
Critical skill for newborn and infant examinations.
Anterior Fontanelle:
- Location: Junction of coronal and sagittal sutures
- Shape: Diamond-shaped
- Size: 1-4 cm (average 2-3 cm at birth)
- Closure: 9-18 months (average 12-15 months)
Posterior Fontanelle:
- Location: Junction of sagittal and lambdoid sutures
- Shape: Triangular
- Size: Usually <1 cm at birth
- Closure: By 2-3 months
Assessment Technique:
- Examine with infant calm, upright or at 45 degrees
- Use fingertips to palpate
- Assess: Size, tension, pulsations
Normal Findings:
- Soft and flat (may be slightly depressed when upright)
- Pulsations present (transmitted arterial pulsations - normal)
- Should not be tense or bulging
Abnormal Findings:
| Finding | Significance | Action |
|---|---|---|
| Bulging fontanelle | Increased intracranial pressure | Urgent evaluation for meningitis, hydrocephalus, hemorrhage |
| Sunken fontanelle | Dehydration | Assess hydration status, feeding |
| Very large fontanelle | May be normal variant or suggest hypothyroidism, skeletal dysplasia | Measure and document; evaluate if >4 cm |
| Early closure | Craniosynostosis | Monitor head circumference growth |
Sutures Assessment
Normal Findings:
- Easily palpable
- Mobile (bones can shift slightly)
- May have slight overlap from molding (resolves)
- Spacing: Should be approximated but not fused
Abnormal Findings:
- Ridged, immobile sutures: Craniosynostosis
- Widely separated: Hydrocephalus, skeletal dysplasia
- Overlapping that persists: Requires follow-up
Clinical Pearls
- Parents often worry about touching fontanelles - reassure them it’s safe
- Anterior fontanelle size varies considerably; if it’s soft and flat, size alone is rarely concerning
- Examine fontanelles when infant is calm - crying can make fontanelle appear full
- Document fontanelle size in two dimensions (length x width)
- Always correlate fontanelle exam with head circumference measurements
Red Flags - When to Worry
- Tense, bulging fontanelle with fever, lethargy, poor feeding
- Progressive head size increase crossing percentiles
- Firm, ridged sutures
- Very large cephalohematoma with overlying scalp laceration (infection risk)
- Depressed skull fracture (palpable step-off)
Lesson 2: Eye Examination
Red Reflex Examination
The red reflex test is a critical screening tool for serious eye pathology. Every newborn should have this examination.
Technique
Equipment:
- Direct ophthalmoscope
- Dim room lighting
Procedure:
- Hold ophthalmoscope 12-18 inches from infant’s eyes
- Shine light directly through both pupils simultaneously
- Observe the red-orange reflection from the retina
- Compare both eyes for symmetry, brightness, color
Normal Red Reflex:
- Bright red-orange color (may be lighter in darkly pigmented infants)
- Equal in both eyes
- Symmetric
- No dark spots or opacities
- No white reflex
Abnormal Red Reflex Findings
Leukocoria (White Pupil/Reflex):
THIS IS AN EMERGENCY - REQUIRES URGENT OPHTHALMOLOGY REFERRAL
Differential Diagnosis:
- Retinoblastoma (malignancy - most concerning)
- Congenital cataract
- Persistent fetal vasculature
- Retinal detachment
- Severe retinopathy of prematurity
- Vitreous hemorrhage
Action: Immediate ophthalmology consultation (same day)
Asymmetric or Diminished Reflex:
- May indicate opacity in visual axis
- Cataract
- Corneal opacity
- Vitreous opacity
Action: Ophthalmology referral (urgent, within days)
Dark Spots in Reflex:
- May be normal variant or small opacity
- Document and follow up
Common Benign Eye Findings
Subconjunctival Hemorrhage:
- Bright red patch on sclera
- Well-demarcated
- Results from birth trauma (pressure changes)
- Red reflex intact
- No visual impact
Clinical Course:
- Resolves spontaneously in 1-2 weeks
- No treatment needed
Parent Counseling: “This is like a bruise on the white part of the eye from delivery. It looks dramatic but doesn’t hurt or affect vision. It will fade away over the next couple weeks, just like a bruise on the skin.”
Conjunctivitis (Ophthalmia Neonatorum):
Must differentiate chemical from infectious causes.
| Timing | Cause | Features | Treatment |
|---|---|---|---|
| Day 1 | Chemical (from eye prophylaxis) | Mild, watery discharge | Observation |
| Days 2-5 | Gonococcal | Profuse purulent discharge, lid swelling | URGENT: IV/IM antibiotics |
| Days 5-14 | Chlamydial | Mucopurulent discharge, conjunctival swelling | Oral erythromycin |
| Variable | HSV | Vesicles, severe inflammation | Antiviral therapy |
Red Flags for Conjunctivitis:
- Profuse purulent discharge
- Lid swelling, erythema
- Corneal involvement (haziness, opacity)
- Systemic signs (fever, lethargy)
Blocked Nasolacrimal Duct:
- Tearing from one or both eyes
- Mucoid discharge, especially in morning
- No erythema or purulent discharge
Management:
- Usually resolves by 6-12 months
- Teach lacrimal massage
- Refer if persists beyond 12 months
Eye Position and Movement
Normal Findings:
- Eyes may not track together initially (immature coordination)
- Transient strabismus in first months is common
- Red reflex should still be present bilaterally
Concerning Findings:
- Fixed deviation
- Constant strabismus
- Nystagmus (rhythmic eye movements)
Clinical Pearls
- Never skip the red reflex examination - it could save a child’s vision or life
- When in doubt about red reflex symmetry, refer to ophthalmology
- Most subconjunctival hemorrhages are benign, but always check red reflex
- Epicanthal folds may give appearance of crossed eyes (pseudostrabismus) - normal
- Pupil size may be unequal (anisocoria) - if red reflex normal and reactive, usually benign
Lesson 3: Ear and Nose Examination
Ear Assessment
External Ear:
- Position: Top of ear should align with outer canthus of eye
- Shape: Examine for tags, pits, abnormal cartilage
- Both ears present and symmetrical
Low-Set Ears:
- May be associated with genetic syndromes (e.g., Down syndrome, trisomy 18)
- Isolated finding often benign
- Consider renal ultrasound if other anomalies present
Preauricular Pits and Tags:
- Common, usually isolated findings
- Pits may rarely connect to sinuses
- Consider hearing screen and renal ultrasound if other anomalies
- Tags can be removed electively for cosmetic reasons
Otoscopic Examination:
- Difficult in newborns due to vernix, small canal
- Often deferred unless symptoms present
- Tympanic membrane may appear dull initially
Nasal Assessment
Patency:
- Newborns are obligate nose breathers
- Must ensure bilateral nasal patency
Choanal Atresia Test:
- If infant appears cyanotic at rest but improves with crying: think choanal atresia
- Can test by: attempting to pass small catheter through each nare
- Bilateral atresia is emergency; unilateral may be asymptomatic
Normal Findings:
- Slight nasal discharge common
- Sneezing common (clears amniotic fluid)
Lesson 4: Oral Cavity Examination
Technique
Always examine oral cavity in every newborn:
- Use good light source
- Insert gloved finger or tongue depressor
- Visualize hard palate, soft palate, uvula
- Assess tongue, frenulum, buccal mucosa
Common Benign Findings
Epstein Pearls:
- Small (1-3 mm) white-yellow bumps
- Along midline of hard palate
- Keratin-filled inclusion cysts
- Firm, cannot be wiped off
Clinical Significance:
- Completely benign
- Resolve spontaneously within weeks
- No treatment needed
- Very common (up to 80% of newborns)
Parent Counseling: “These little white bumps are very common and completely harmless. They’re small cysts that will go away on their own in the next few weeks.”
Natal Teeth:
- Teeth present at birth
- Usually lower central incisors
- Often poorly rooted
Management:
- Remove if very loose (aspiration risk)
- Remove if interfering with feeding or causing tongue irritation
- Otherwise can leave in place
Pathological Findings Requiring Intervention
Cleft Lip and Palate:
Types:
- Cleft lip only
- Cleft palate only (may involve hard palate, soft palate, or both)
- Combined cleft lip and palate
Immediate Assessment:
- Can infant feed safely?
- Is there nasal regurgitation?
- Airway stable?
Management:
- Multidisciplinary team: plastic surgery, ENT, genetics, feeding specialist, speech therapy
- Special feeding techniques/equipment (Haberman feeder, palatal obturator)
- Surgical repair typically at 3-6 months (cleft lip), 9-18 months (cleft palate)
- Genetic evaluation (many syndromes include cleft palate)
Parent Support:
- Provide immediate emotional support
- Connect with cleft team before discharge
- Ensure adequate feeding plan
- Show photos of successful repairs
Ankyloglossia (Tongue-Tie):
Definition:
- Tight or short lingual frenulum
- Restricts tongue mobility
Classification:
- Type 1-2: Anterior (more obvious)
- Type 3-4: Posterior (subtle, may be missed)
Assessment:
- Tongue mobility: Can infant elevate tongue to palate?
- Appearance: Heart-shaped tongue when crying
- Function: Is breastfeeding affected?
- Poor latch
- Sliding off nipple
- Clicking sounds
- Maternal nipple pain
- Infant frustration
- Poor weight gain
Functional Significance: Not all tongue-ties need treatment. Assess feeding function.
Indications for Frenotomy:
- Documented feeding difficulties
- Poor latch, maternal pain
- Poor weight gain
- Infant frustration at breast
Procedure:
- Simple, quick office procedure
- Minimal bleeding
- Immediate feeding improvement in many cases
When to Watch and Wait:
- Tongue-tie present but feeding well
- No maternal nipple trauma
- Adequate weight gain
Oral Thrush (Candida):
- White plaques on tongue, buccal mucosa
- Can be wiped off (unlike Epstein pearls), leaving red base
- May cause feeding difficulty
Treatment:
- Nystatin oral suspension
- Treat maternal nipples if breastfeeding
- Usually resolves in 1-2 weeks
Clinical Pearls
- Always palpate the entire palate - visual inspection alone can miss submucous cleft
- Posterior tongue-tie is often missed; if breastfeeding difficulties, lift tongue to examine
- Not all tongue-ties require treatment - function matters more than appearance
- Bifid uvula may indicate submucous cleft palate - needs follow-up
- White patches: If they wipe off = thrush; if they don’t = Epstein pearls
Red Flags - When to Worry
- Any cleft palate (requires team approach)
- Micrognathia with respiratory distress (Pierre Robin sequence)
- Large oral mass (teratoma, hemangioma)
- Excessive drooling, inability to swallow secretions
- Feeding difficulties despite adequate latch/technique
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Exercise 2.1: Cranial Findings Assessment
Let’s practice identifying and managing common cranial findings in newborns.
Exercise 2.1: Cranial Findings - Fontanelles and Sutures
🎯 Your Challenge
Examine the clinical descriptions of different cranial findings in newborns. For each case, identify the finding, determine if it's normal/benign/pathological, explain the expected course, and provide appropriate parent counseling.
📋 View Clinical Cases
Exercise 2.2: Eye Examination and Red Reflex
Practice identifying normal and abnormal eye findings, with emphasis on the critical red reflex examination.
Exercise 2.2: Eye Exam - Red Reflex and Common Findings
🎯 Your Challenge
Review eye examination findings in newborns. Identify the findings, recognize red flags that require urgent referral, differentiate benign from pathological conditions, and provide appropriate parent education.
📋 View Eye Examination Cases
Exercise 2.3: Oral Cavity Findings
Develop skills in identifying oral findings, assessing functional impact, and determining appropriate management.
Exercise 2.3: Oral Cavity - Tongue-Tie, Cleft, and Other Findings
🎯 Your Challenge
Examine oral cavity findings in newborns. Identify the findings, assess their functional significance (especially for feeding), determine need for intervention or referral, and provide comprehensive parent counseling.
📋 View Oral Examination Cases
Module 2 Complete! 🎉
Congratulations on completing Module 2! You’ve developed essential skills in HEENT examination:
✅ Identifying cranial findings and understanding their natural history ✅ Performing and interpreting the critical red reflex examination ✅ Recognizing benign oral findings versus those requiring intervention ✅ Assessing functional impact of oral findings on feeding ✅ Knowing when urgent referral is needed
Key Takeaways
- Caput vs Cephalohematoma - Remember: caput crosses sutures and resolves quickly; cephalohematoma doesn’t cross sutures and resolves slowly
- Red Reflex is Critical - Never skip this exam. Leukocoria requires urgent ophthalmology referral
- Subconjunctival Hemorrhage - Common, benign, and self-resolving despite dramatic appearance
- Epstein Pearls - Very common, completely benign, no treatment needed
- Tongue-Tie Management - Function matters more than anatomy; only treat if affecting feeding
- Cleft Palate - Requires multidisciplinary team approach; ensure feeding plan before discharge
- Parent Reassurance - Many dramatic-looking findings (caput, subconjunctival hemorrhage, Epstein pearls) are benign
Critical Safety Points
RED FLAGS requiring urgent action:
- Leukocoria (white pupil) - ophthalmology referral same day
- Bulging fontanelle with fever/lethargy - rule out meningitis
- Any cleft palate - ensure safe feeding and team referral
- Profuse purulent eye discharge days 2-5 - rule out gonococcal conjunctivitis
What’s Next?
In Module 3, you’ll learn cardiovascular and respiratory examination skills. You’ll practice auscultation techniques, recognize innocent versus pathological murmurs, and identify signs of respiratory distress.