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10-2

Key Points

Ball: Seidel’s Guide to Physical Examination, 8th Edition

Chapter 10: Head and Neck

Key Points

This review discusses examination of the head and neck.

Before the exam, gather the necessary equipment: a tape measure, stethoscope, cup of water, and transilluminator.

To examine the head and face, perform the following.

Start with inspection, including six characteristics.

First, observe the head position, which should be upright and still.

Second, inspect the facial features, including the eyelids, eyebrows, palpebral fissures, nasolabial folds, and mouth, noting their shape and symmetry at rest and with movement and expression. Slight asymmetry is common for any patient. If facial asymmetry is present, determine if it affects all features on one side of the face or only some.

Third, watch for tics, which are spasmodic muscular contractions of the face, head, or neck.

Fourth, note any change in the shape of the face or any unusual features, such as edema, prominent eyes, or hirsutism. Be alert for characteristic facies that suggest a clinical condition or syndrome.

Fifth, inspect the skull for size, shape, and symmetry.

Sixth, examine the scalp by systematically parting the hair from the frontal to the occipital region. Note any lesions, tenderness, nits, scaliness, or hair loss pattern.

Move on to palpation of the head in five areas.

First, gently and systematically palpate the skull from front to back. The skull should feel symmetrical and smooth. The scalp should move freely over it and should have no tenderness, swelling, or depressions.

Second, palpate the hair, noting its texture, color, and distribution. It should be smooth and symmetrically distributed with no split ends.

Third, assess the temporal arteries. Notice any thickening, hardness, or tenderness, which may signal temporal arteritis.

Fourth, palpate both temporomandibular joint spaces to detect pain, crepitus, locking, or popping.

Fifth, if the salivary glands appear asymmetrical or enlarged, palpate to determine the discreteness, mobility, texture, and tenderness of the enlargement. With the patient’s mouth open, press on the gland to try to express material through the salivary duct.

Although percussion and auscultation of the head are not routinely performed, these techniques may help detect signs of two disorders.

On percussion of the masseter muscle, facial spasms may be associated with hypercalcemia.

On auscultation of the temporal region, over the eyes, and below the occiput, a bruit suggests a vascular anomaly.

To examine the neck, perform the following.

Start with inspection of the neck in its usual position, in slight hyperextension, and when the patient swallows. Note six characteristics.

First, observe for bilateral symmetry of the sternocleidomastoid and trapezius muscles.

Second, check for alignment of the trachea.

Third, observe the landmarks of the anterior and posterior triangles.

Fourth, note any fullness at the base of the neck.

Fifth, look for such abnormalities as masses, webbing, excess skinfolds, unusual shortness, or asymmetry.

Sixth, observe for jugular vein distention and carotid artery prominence, which should not be present.

Evaluate range of motion by having the patient flex, extend, rotate, and laterally turn the head and neck. Movement should be smooth and painless without causing dizziness.

Test muscle strength by placing one hand on the check and jaw and asking the patient to turn toward your hand while you apply resistance. Have the patient shrug their shoulders while you apply resistance. Remember that these maneuvers do double duty because they also test cranial nerve XI .

Move on to palpation of the neck in five areas.

First, palpate the trachea by placing a thumb along each side of the trachea and comparing the space between it and the sternocleidomastoid muscles. The trachea should be midline.

Second, feel for the hyoid bone and the thyroid and cricoid cartilages. They should be smooth and nontender and should move under your finger when the patient swallows.

Third, check for a tracheal tug. With the patient’s neck extended, place your index finger and thumb on each side of the trachea below the thyroid isthmus. Tracheal tugging in time with the pulse suggests an aortic aneurysm.

Fourth, palpate the paravertebral muscles and posterior spinous processes, noting any areas of tenderness.

Fifth, inspect and palpate the lymph nodes of the head and neck, as described in the audio review of the lymphatic system.

To examine the thyroid gland, perform the following.

Inspect the thyroid gland with the patient’s neck extended. Provide a cup of water and observe from the side as the patient swallows. Note the gland’s size, symmetry, contour, and movement with swallowing.

Palpate the thyroid gland while in front of—or behind—the patient. With either approach, follow these two examination tips.

First, flex the patient’s neck slightly forward and toward the side being examined.

Second, have the patient hold a sip of water in the mouth until your hands are in place and you tell the patient to swallow.

For the frontal approach, face the patient who is seated on the exam table. Then follow these four steps.

First, place your thumb over the trachea about 3 cm below the thyroid cartilage.

Second, feel for the isthmus of the gland as the patient swallows.

Third, palpate the left lobe by pressing the trachea to the left with your left thumb and placing the first three fingers of your right hand in the thyroid bed with your fingertips medial to the margin of the sternocleidomastoid muscle. When the patient swallows, feel for the gland to move.

Fourth, palpate the right lobe by moving your hands to the opposite corresponding positions.

For the approach from behind, stand behind the patient who is seated in a chair. Then follow these four steps.

First, place two fingers of each hand on the sides of the trachea just beneath the cricoid cartilage.

Second, feel for the isthmus of the gland as the patient swallows.

Third, palpate the left lobe by displacing the trachea to the left with your right fingers and placing the first three fingers of your left hand medial to the left sternocleidomastoid muscle. When the patient swallows, feel for the gland to move.

Fourth, palpate the right lobe by moving your hands to the opposite corresponding positions.

Using either approach, palpate the thyroid gland’s size, shape, configuration, and consistency and note any tenderness or nodules. If you’re not sure whether you’re feeling the thyroid gland, remember that the thyroid gland moves with swallowing; subcutaneous fat mimicking a goiter does not.

If felt, the thyroid lobes should be small, smooth, firm, pliable, and free of nodules. The gland should rise freely with swallowing and should be about 4 cm wide.

If the thyroid gland is enlarged, auscultate it for bruits using the bell of the stethoscope.