Chapter 13 Head, Face, and Neck, Including Regional Lymphatics PDF

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Ms. Ann St.Germain, Lecture Week 5. Houston Campus.

Physical Examination and Heath Assessment, Carolyn Jarvis, 7th Edition ...

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Chapter 13: Head, Face, and Neck, Including Regional Lymphatics The Head ★ Skull - rigid bony box that protects the brain and special sense organs ★ Cranial bones: ○ Frontal ○ Parietal ○ Occipital ○ Temporal ★ Cranial sutures ○ Coronal suture - crowns the head from ear to ear at the union of frontal and parietal bones ○ Sagittal suture - separates the head lengthwise between parietal bones ○ Lambdoid suture - separates the parietal bones crosswise from the occipital bone ★ Facial bones ○ Nasal bone ○ Zygomatic bone ○ Maxilla ○ Mandible ★ Cranium is supported by the cervical vertebrae: C1 (axis), C2 (atlas) through C7 (vertebra prominens) ★ The face: ○ Facial muscles mediated by cranial nerve VII ○ Facial muscle function is symmetric bilaterally ○ Facial structures are symmetrical: eyebrows, eyes, ears, nose, mouth, palpebral fissures, nasolabial folds ○ Facial sensations of touch are mediated by cranial nerve V (trigeminal nerve) ○ Salivary glands: ■ Parotid glands - in the cheeks over the mandible; largest salivary glands but not normally palpable ■ Submandibular glands - beneath the mandible at the angle of the jaw ■ Sublingual glands - lie in the floor of the mouth ○ Temporal artery - superior to the temporalis muscle and its pulsation is palpable anterior to the ear ★ The Aging Adult ○ Facial bones and orbits appear more prominent ○ Facial skin sags

The Neck ★ Major neck muscles ○ Sternomastoid - arises from the sternum and clavicle and extends diagonally to

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the mastoid process behind the ear; it accomplishes head rotation and flexion ○ Trapezius - arise from occipital bone and vertebrae, extend to the scapula and clavicle; move the shoulders and extend and turn the head Landmarks ○ Anterior triangle - lies in front between the sternomastoid and midline of the body, with its base up along the lower border of the mandible and its apex at the suprasternal notch ○ Posterior triangle - behind the sternomastoid muscle, with the trapezius muscle on the other side and its base along the clavicle Thyroid Gland ○ Straddles the trachea in the middle of the neck ○ Synthesizes and secretes thyroxine and triiodothyronine that stimulate rate of cellular metabolism ○ Two lobes that curve posteriorly between trachea and sternomastoid muscle and connect in the middle (isthmus). Cricoid cartilage ○ Just above the thyroid isthmus - upper tracheal ring Thyroid cartilage ○ Above the cricoid cartilage with a small palpable notch in its upper edge ○ “Adam’s apple” in males Hyoid bone ○ Palpated high in the neck at the level of the floor of the mouth

Lymphatics ★ Head and neck have 60 to 70 lymph nodes ○ Preauricular - in front of the ear ○ Posterior auricular - superficial to the mastoid process ○ Occipital - at the base of the skull ○ Submental - midline, behind the tip of the mandible ○ Submandibular - halfway between the angle and the tip of the mandible ○ Jugulodigastric (tonsillar) - under the angle of the mandible ○ Superficial cervical - overlying the sternomastoid muscle ○ Deep cervical - deep under the sternomastoid muscle ○ Posterior cervical - in the posterior triangle along the edge of the trapezius muscle ○ Supraclavicular - just above and behind the clavicle at the sternomastoid muscle ★ Drainage patterns ○ When nodes are enlarged, check the area they drain. ○ All drain down expect for supraclavicular, which drains up

Subjective Data

★ Headache ○ An unusually frequent or unusually severe headaches? ○ OLDCARTS ○ Ever had this kind of headache before? ○ Do you have any other illnesses? ○ Do you take any medications? ○ Any family history of headaches? ○ Tension headaches: ■ occipital or frontal with bandlike tightness ■ Viselike ■ Associated with anxiety and stress ○ Migraines: ■ Vascular ■ tend to be supraorbital, retroorbital, or frontotemporal ■ throbbing, severe pain ■ occur twice per month, each lasting 1 to 3 days ■ alcohol, stress, menstruation, chocolate, cheese precipitate ■ associated with N/V and visual disturbances ■ Family history ■ People lie down to feel better ○ Cluster headaches: ■ produce pain around the eye, temple, forehead, cheek ■ unilateral on same side of head ■ excruciating pain ■ occur once or twice per day, each lasting ½ to 2 hours ■ alcohol and daytime napping precipitate ■ Associated with eye reddening and tearing, eyelid drooping, rhinorrhea and nasal congestion ■ People need to move to feel better ○ Hypertension, fever, hypothyroidism, vasculitis, oral contraceptives, bronchodilators, alcohol, nitrates, and carbon monoxide inhalation can cause headaches ○ How have these headaches affected your self-care or ability to function? ★ Head injury ○ Any head injury or blow to your head? ○ OLDCARTS ○ Are symptoms worse, better, or unchanged since injury? ○ Loss of consciousness before a fall may have a cardiac cause ○ A change in LOC is most important in evaluating a neurologic deficit ★ Dizziness ○ Experienced any dizziness?

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○ Describe it for me ○ Presyncope: a light-headed, swimming sensation or feeling of fainting or falling caused by decreased blood flow to the brain or heart irregularity causing decreased cardiac output. ○ Vertigo: true rotational spinning often from labyrinthine-vestibular disorder in inner ear ■ Objective vertigo: the person feels like the room is spinning ■ Subjective vertigo: the person feels like he or she is spinning ○ Disequilibrium: a shakiness or instability when walking related to musculoskeletal disorder or multi-sensory deficits Neck Pain ○ OLDCARTS ○ Acute onset of neck stiffness with headache and fever occurs with meningeal inflammation Lumps or Swelling ○ Any recent tenderness or infection? ■ Tenderness suggests acute infection ■ Persistent lump arouses suspicion of malignancy ○ Any history of irradiation of head, neck, upper chest? ■ Increased risk for salivary and thyroid tumors ○ Any difficult swallowing? ■ Dysphagia ○ Smoking history ■ Smoking and chewing tobacco increases risk for oral and respiratory cancer ○ Alcohol history ■ Increases risk for cancer when combined with smoking ○ Thyroid problems? History of head or neck surgery ○ Ever had surgery of the head or neck? ■ Can cause disfigurement and increases risk for body image disturbance ○ For what condition? ○ When was the surgery? ○ How do you feel about the results? The Aging Adult ○ Patient-centered care: how does condition affect ADL’s and IADL’s? ■ Assess potential for injury

Objective Data The Head

★ Inspect and Palpate the Skull ○ Size and shape ■ Normocephalic - a round symmetric skull that is appropriately related to body size ■ Microcephalic - abnormally small head ■ Hydrocephalic/Acromegaly - abnormally large head ■ Place fingers in person’s hair and palpate scalp. No tenderness to palpation ■ Note lumps, depressions, or abnormal protrusions ○ Temporal area ■ Palpate the temporal artery above the zygomatic bone between the eye and the top of the ear ● Note if the artery looks tortuous, feels hardened, or is tender ■ The temporomandibular joint is just below the temporal artery ● Palpate as the person opens the mouth ● Observe smooth movement with no limitation or tenderness ● Abnormal: crepitation, limited ROM, tenderness ★ Inspect the Face ○ Facial structures ■ Note facial expression and appropriateness to behavior or reported mood ● Anxiety is common in hospitalized or ill person ○ Tense, rigid muscles ● Note hostility or aggression ● Flat affect may indicate depression ■ Features should always be symmetric - eyebrows, palpebral fissures, nasolabial folds, sides of mouth ● Marked asymmetry with central brain lesion (stroke), cranial nerve VII damage (Bell palsy) ■ Note any abnormal facial structures ● Coarse features, exophthalmos, changes in skin color/pigmentation ■ Note abnormal swelling ● Edema occurs first around the eyes and cheeks (where subQ tissue is loose) ■ Note involuntary movements ● Tics, grinding of jaws, fasciculations, excessive blinking The Neck ★ Inspect and Palpate the Neck ○ Symmetry ■ Head position is centered in midline ■ Accessory neck muscles should be symmetric ■ Head should be erect and still ■ Head tilt occurs with muscle spasm

■ Rigid head and neck occur with arthritis ○ Range of Motion ■ Note any limitation or pain of movement ■ Ask person to perform ROM ● Motion should be smooth and controlled ● Ratchety or limited movement could be from cervical arthritis or inflammation of neck muscles ■ Cranial nerve XI ● Try to resist person from shrugging shoulders and turning head from side to side ■ Note enlargement of salivary or lymph glands ● Swollen parotid gland can be seen when head is extended swelling below angle of jaw ● Thyroid enlargement may be unilateral or diffuse ● Parotid can be swollen with mumps or AIDS ■ Note any obvious pulsations (carotid) ★ Lymph Nodes ○ Use gentle circular motion of finger pads ○ Begin with preauricular nodes and move in systematic order ○ Use gentle pressure ○ Compare bilaterally ○ Note location, size, shape, delimitation, mobility, consistency, and tenderness ○ Normal nodes feel movable, discrete, soft, and nontender ○ Lymphadenopathy: enlargement of lymph nodes (> 1 cm) from infection, allergy, or neoplasm ○ If nodes are enlarged or tender, check the area they drain for the source of the problem ■ Acute infection: acute onset, < 14 days duration, nodes are bilateral, enlarged, warm, tender, and firm, but freely movable ■ Chronic inflammation: in TB the nodes are clumped ■ Cancerous nodes: hard, > 3 cm, unilateral, nontender, matted, fixed ■ HIV infection: enlarged, firm, nontender, mobile (occipital node) ■ Neoplasm in thorax or abdomen: single, enlarged, nontender, hard, left supraclavicular node ■ Hodgkin lymphoma: painless, rubbery, discrete, gradually appear, commonly in cervical region ★ Trachea ○ Normally the trachea is midline ○ Trachea is pushed to unaffected (healthy) side with aortic aneurysm, tumor, unilateral thyroid lobe enlargement, pneumothorax ○ Trachea is pulled toward affected (diseased) side with large atelectasis, pleural

adhesions, or fibrosis ○ Tracheal tug - a rhythmic downward pull that is synchronous with systole and occurs with aortic arch aneurysm ★ Thyroid Gland ○ Difficult to palpate ○ Look for diffuse enlargement or a nodular lump ○ Usually you cannot palpate the normal adult thyroid ○ Sometimes feel the isthmus over the tracheal rings ○ If the thyroid is enlarged, auscultate it for the presence of a bruit (a soft, pulsatile, whooshing, blowing sound heard best with the bell) The Aging Adult ★ Temporal arteries may look twisted and prominent ★ Senile tremors - mild rhythmic tremor of the head such as nodding and tongue protrusion ★ If teeth have been lost, lower face looks abnormally small with mouth sunken in ★ Kyphosis ★ Perform ROM slowly ★ Prolapse of submandibular glands...