Health Assessment 06

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Chapter 14

Head, Face, and Neck, and Regional Lymphatics

Structure and Function: Head (1 of 2)

Skull is rigid box that protects brain.

Includes bones of cranium and face

Supported by cervical vertebra

Cranial bones

Frontal

Parietal

Occipital

Temporal

Sutures—adjacent cranial bones mesh at sutures

Coronal

Sagittal

Lambdoid

Structure and Function: Head (2 of 2)

14 facial bones also articulate at sutures.

Facial expressions formed by facial muscles, which are mediated by cranial nerve VII, the facial nerve

Two pairs of salivary glands accessible to examination on the face:

Parotid glands are in cheeks over mandible, anterior to and below ear; the largest of salivary glands, they are not normally palpable.

Submandibular glands beneath mandible at angle of jaw

Third pair, sublingual glands, lies in floor of mouth.

Temporal artery lies superior to temporalis muscle, and pulsation is palpable anterior to ear.

Structure: Head

Structure and Function: Neck

Neck delimited by

Base of skull and inferior border of mandible above, and by manubrium sterni, clavicle, first rib, and first thoracic vertebra below

Think of neck as conduit of many structures.

Vessels, muscles, nerves, lymphatics, and viscera of respiratory and digestive systems

Internal carotid branches off common carotid and runs inward and upward to supply brain.

External carotid supplies face, salivary glands, and superficial temporal area.

Structure and Function: Neck Muscles

Major neck muscles

Sternomastoid and trapezius are innervated by cranial nerve XI.

Sternomastoid enables

Head rotation and flexion and divides each side of neck into two triangles: anterior and posterior triangles

Two trapezius muscles move shoulders and extend and turn head.

Structure and Function: Thyroid

Endocrine gland

Straddles trachea in middle of the neck

Synthesizes and secretes

Thyroxine (T4) and triiodothyronine (T3), which are hormones that stimulate rate of cellular metabolism

The gland has two lobes

Connected in middle by a thin isthmus and above that by the cricoid cartilage or upper tracheal ring

Thyroid cartilage

Small palpable notch in upper edge (“Adam’s apple” in males)

Cricoid cartilage or upper tracheal ring

Isthmus of the thyroid gland

Structures of Neck

Structure and Function: Lymphatic System

Major part of immune system

Detects and eliminates foreign substances from body

Rich supply of lymph nodes

Greatest supply is in head and neck.

Lymphatic drainage

Helps to prevent potentially harmful substances from entering the circulation

You should be familiar with direction of drainage patterns of lymph nodes.

Drainage Patterns of Lymph Nodes

Structure and Function: Lymph Nodes (1 of 2)

Preauricular

In front of ear

Posterior auricular (mastoid)

Superficial to mastoid process

Occipital

At base of skull

Submental

Midline, behind tip of mandible

Submandibular

Halfway between angle and tip of mandible

Structure and Function: Lymph Nodes (2 of 2)

Jugulodigastric

Under angle of mandible

Superficial cervical

Overlying sternomastoid muscle

Deep cervical

Deep under sternomastoid muscle

Posterior cervical

In posterior triangle along edge of trapezius muscle

Supraclavicular

Just above and behind clavicle, at sternomastoid muscle

Locations of Lymph Nodes

Developmental Competence: Infants and Children (1 of 2)

Bones of neonatal skull are separated by sutures and fontanels, spaces where the sutures intersect.

These membrane-covered “soft spots” allow growth of brain during first year; gradually ossify.

Closure of fontanels

Triangle-shaped posterior fontanel closes by 1 to 2 months.

Diamond-shaped anterior fontanel closes between 9 months and 2 years.

During fetal period, head growth predominates.

Head size is greater than chest circumference at birth and reaches 90% of final size at 6 years old.

Developmental Competence: Infants and Children (2 of 2)

During infancy, trunk growth predominates

so that head size changes in proportion to body height.

Facial bones grow at varying rates.

In toddler, mandible and maxilla are small and nasal bridge is low.

Lymphoid tissue

Well developed at birth and grows to adult size when the child is 6 years old

In adolescence

facial hair also appears on boys at this time: first on upper lip, then on cheeks and lower lip, and last on the chin.

noticeable enlargement of the thyroid cartilage occurs, and with it, the voice deepens.

Developmental Competence

Pregnant female

Thyroid gland enlarges slightly during pregnancy as a result of hyperplasia of tissue and increased vascularity.

Aging adult

Facial bones and orbits appear more prominent.

Facial skin sags resulting from decreased elasticity, decreased subcutaneous fat, and decreased moisture in skin.

Lower face may look smaller if teeth have been lost.

Headache

Leading cause of acute pain and lost productivity

Classified by etiology and often misdiagnosed

Chronic migraine

More than 15 days per month

Gender difference

More common in females than males with peak in midlife seen equally

Ethnic difference

More prevalent among Caucasian and Hispanic population

Various etiological theories proposed

Culture and Genetics

Headache

Head injury

Dizziness

Neck pain, limitation of motion

Lumps or swelling

History of head or neck surgery

Subjective Data: Health History

Ask about

onset pattern characteristics.

location pattern.

pain characteristics.

course and duration.

precipitating factors.

associated factors.

alleviating factors.

what makes it worse.

presence of comorbidities.

medication history.

patient-centered care.

Health History Questions: Headaches

Health History Questions: Head Injury

Ask about

onset, setting, and description of injury.

changes in levels of consciousness.

loss of consciousness and/or fall

history of comorbidity.

location of injury.

pattern of symptoms.

presence of associated symptoms.

treatment plan

emergency, hospitalization, and/or medication.

Dizziness

Provide a description of “feeling” in patient’s own words

Associated with change of position, nausea, and/or vomiting

Neck pain

Onset, location, associated symptoms, limitation of ROM, precipitating factors, stress

Focus on patient-centered care

Lumps or swelling

History of recent infection, radiation, smoking, alcohol, difficulty swallowing, thyroid issues

History of head or neck surgery

Type of surgery, reason for surgery, response to surgery

Other Health History Questions

Additional Health History Questions

For infants and children

Maternal alcohol or drug use?

Type of delivery?

Vaginal or by cesarean section? Any difficulty? Use of forceps?

Growth pattern?

Was it on schedule?

For aging adults—patient-centered care

Dizziness and/or neck pain

How does it affect your daily activities?

Inspection and Palpation of the Skull

Size and shape

Normocephalic: round and symmetric

Assess shape: place fingers in person’s hair and palpate scalp

Cranial bones that have normal protrusions:

Forehead, lateral edge of parietal bones, occipital bone, and mastoid process behind each ear

Temporal area

Palpate temporal artery above zygomatic (cheek) bone between eye and top of ear

Inspection of the Face

Facial structures

Always should be symmetric.

Note facial expression and appropriateness to behavior or reported mood.

Note any abnormal facial structures

Coarse facial features, exophthalmos, changes in skin color or pigmentation, or abnormal swellings

Note any involuntary movements (tics) in facial muscles; normally none occur.

Head and neck symmetry

Head position is centered in midline, and accessory neck muscles should be symmetric.

Head should be held erect and still.

Range of motion

Note any limitations.

Test muscle strength.

Observe for enlargement of glands and/or pulsations.

Lymph nodes

Palpate nodes noting location, size, shape, delimitation, mobility, consistency, and tenderness.

Inspection and Palpation of the Neck (1 of 2)

Trachea

Should be midline

Palpate for any tracheal shift

Note any deviation from midline

Thyroid gland

Difficult to palpate; check for enlargement, consistency, symmetry, and presence of nodules

Position patient for best approach

Posterior approach

Anterior approach

Auscultate thyroid for bruit, if enlarged.

Inspection and Palpation of the Neck (2 of 2)

Examining Lymph Nodes

Using a gentle circular motion of finger pads, palpate lymph nodes.

Beginning with preauricular lymph nodes in front of ear, palpate the 10 groups of lymph nodes in routine order

Many nodes are closely packed, so you must be systematic and thorough in your examination.

Do not vary sequence or you may miss some small nodes.

Thyroid Palpation: Anterior Approach

Thyroid Palpation: Posterior Approach

Physical Examination: Infants and Children (1 of 2)

Skull

Measure infant’s head at each visit up to age 2 years and yearly up to age 6 years.

Note infant’s head posture and head control; infant can turn head side to side by 2 weeks.

Two common variations in newborn cause shape of skull to look markedly asymmetric due to birth trauma:

Caput succedaneum: edematous swelling that is self-limiting and extends across suture lines

Cephalohematoma: subperiosteal hemorrhage, well defined over one cranial bone over periosteum, reabsorbed during first few weeks of life

Physical Examination: Infants and Children (2 of 2)

Skull

Molding

Overriding of the cranial bones during birth process that resolves over a few days or a week

Positional molding (positional plagiocephaly)

Flattening of the head due to infant sleeping position

Fontanels

Observe anterior and posterior fontanel.

Head and neck control

Observe for appearance of tonic neck reflex which disappears between 3 and 4 months of age.

Physical Examination: Infants and Children: Face

Check facial features for symmetry, appearance, and swelling.

Note symmetry of wrinkling when infant cries or smiles (e.g., both sides of lips rise and both sides of forehead wrinkle).

Normally, no swelling is evident.

Parotid gland enlargement best seen when child looks up; swelling appears below angle of jaw

Physical Examination: Infants and Children: Neck

An infant’s neck looks short; it lengthens during the first 3 to 4 years.

Assess muscle development with gentle passive ROM.

Cradle infant’s head with your hands and turn it side to side and test forward flexion, extension, and rotation.

Note resistance to movement, especially flexion.

During infancy, cervical lymph nodes are not palpable normally, but child’s lymph nodes are palpable.

Palpable nodes less than 3 mm are normal.

Children have a higher incidence of infection, so you will expect a greater incidence of inflammatory adenopathy; no other mass should occur in neck.

Infants and Children: Special Procedures

Percussion

With an infant, you may directly percuss with your plexor finger against head surface.

This yields a resonant or “cracked pot” sound, which is normal before closure of fontanels.

Auscultation

Bruits are common in skull of children under 4 or 5 years of age or children with anemia.

Systolic or continuous; heard over temporal area

Physical Examination: Pregnant Female

During second trimester

chloasma may show on face.

A blotchy, hyperpigmented area over cheeks and forehead that fades after delivery

Thyroid gland may be palpable normally during pregnancy.

Physical Examination: Aging Adult

Temporal arteries

may look twisted and prominent.

In some aging adults, a mild rhythmic tremor of head may be normal.

senile tremors are benign and include head nodding and tongue protrusion.

If some teeth have been lost

lower face looks unusually small, with mouth sunken in.

Neck may show an increased concave curve

to compensate for kyphosis.

Maintain patient safety by indicating patient perform ROM and position changes slowly

minimize potential for dizziness.

Diagnosed by patient history with no abnormal findings on exam or laboratory results

Types of headaches:

Tension, migraine, and cluster

Factors to review:

Definition, location, character, duration, quantity and severity, and timing

Aggravating symptoms or triggers, associated symptoms and relieving factors, effort to treat

Abnormal Findings: Primary Headaches

Abnormal Findings: Pediatrics (1 of 2)

Hydrocephalus

Obstruction of drainage of cerebrospinal fluid results in excessive accumulation, increasing intracranial pressure, and enlargement of the head,

Down syndrome

Most common chromosomal abnormality with characteristic facial abnormalities

Upslanting eyes with inner epicanthal folds

Flat nasal bridge and small, broad nose

Protruding thick tongue and ear dysplasia

Broad neck with webbing and small hands with single palmar crease

Plagiocephaly

Positional or deformational due to sleeping position

Abnormal Findings: Pediatrics (2 of 2)

Craniosynostosis

Premature closing of one or more cranial sutures that leads to head malformation

Atopic (allergic) facies

A variety of presentations seen in children who have chronic allergies

Include exhausted face, allergic shiners, Morgan lines, central facial pallor and allergic gaping

Fetal alcohol spectrum disorders (FASD)

Narrow palpebral fissures, epicanthal folds, thin upper lip, and midfacial hypoplasia

Allergic salute and crease

Appearance of transverse line on the nose in response to chronically repeated use of hand to push the nose up and back

Fetal Alcohol Spectrum Disorders (FASD)

Abnormal Findings: Swellings of Head and Neck

Congenital torticollis

Hematoma in one sternomastoid muscle, probably injured by intrauterine malposition, results in head tilt to one side and limited neck ROM to opposite side

Simple diffuse goiter (SDG)

Endemic goiter due to iodine deficiency that results in chronic enlargement of the thyroid gland

Thyroid—multinodular goiter (MNG)

Multiple nodules usually indicate inflammation or multinodular goiter rather than a neoplasm; however, suspect any rapidly enlarging or firm nodule

Pilar cyst (Wen)

Benign growth that presents as smooth, fluctuant swelling on scalp

Parotid gland enlargement

Rapid painful enlargement seen in response to mumps, blockage of duct, abscess, or tumor

Thyroid Disorders: Graves Disease

Physical presentation neck and face

Goiter

Eyelid retraction

Exophthalmos

Thyroid Disorders: Hypothyroidism

Physical presentation neck and face

Puffy edematous face

Periorbital edema

Coarse facial features

Coarse hair and eyebrows

Acromegaly

Elongated head, massive face, overgrowth of nose, lower jaw, heavy eyebrow ridge, and coarse facial features

Cushing syndrome

Classic “moonlike” face, red cheeks, and hirsutism

Bell palsy

Paralysis on one side of the face as a result of LMN lesion

Stroke or brain attack

UMN lesion leading to paralysis of lower facial muscles

Parkinson syndrome

Classic “maskline” appearance, elevated eyebrows, staring gaze, oily skin and drooling due to dopamine deficiency

Cachectic appearance

Sunken eyes, hollow cheeks, and defeated expression that accompanies chronic wasting diseases

Abnormal Facial Appearances Associated with Chronic Illnesses

Summary Checklist: Head, Face, and Neck, including Regional Lymphatics Examination

Inspect and palpate the skin.

General size and contour.

Note any deformities.

Palpate temporal artery and temporomandibular join (TMJ) joint.

Inspect and palpate the face.

Observe facial expression.

Cranial nerve VII: symmetry of movement.

Observe for any abnormal movements.

Inspect and palpate the neck.

Active ROM, potential enlargement and position of trachea

Auscultate thyroid (if enlarged) for bruit.