HEENT Assessment

A unilateral pupil that won't constrict tells you more about intracranial pressure than any headache scale ever will — but only if you know what normal looks like first.

HEENT assessment is a systematic head-to-toe evaluation of the head, eyes, ears, nose, and throat. Start with the head: inspect for symmetry, palpate the skull for masses or tenderness, and note facial symmetry by asking the patient to smile and raise eyebrows (asymmetry suggests cranial nerve VII dysfunction). For eyes, test visual acuity (Snellen chart — 20/20 is normal), inspect sclera (yellow = jaundice, red = hemorrhage or infection), and assess pupils using PERRLA: Pupils Equal, Round, Reactive to Light, and Accommodation. Normal pupil size is 2–6 mm; document size, shape, and briskness of response. A sluggish or fixed unilateral pupil is a medical emergency suggesting increased ICP. For ears, inspect the pinna, assess hearing with the whisper test (stand 1–2 feet away), and note any drainage — clear fluid from the ear after head trauma suggests CSF leak (positive halo sign). For the nose, check patency of each naris and inspect for septal deviation or bleeding. For the throat, use a tongue depressor and penlight to inspect the pharynx, tonsils (graded 1+ to 4+), and uvula — the uvula should be midline. Note any exudate, erythema, or asymmetry.

Key Distinctions

Don't confuse PERRLA documentation with a neurological assessment — PERRLA is part of HEENT but a unilateral fixed dilated pupil crosses into neuro emergency territory and must be escalated immediately. Students often test accommodation but forget the consensual reflex: shining light in one eye should constrict both pupils. Tonsil grading (1+ visible, 4+ touching midline) is a HEENT finding, not a respiratory one.

Clinical Pearl

PERRLA is your pupil checklist — but new-onset unequal pupils with a non-reactive dilated side are never normal. When one pupil stops reacting, stop assessing and start calling.