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PDx – PAST 581 Head and Neck 11/16/18 1. Anatomy a. Skull comprised of 7 bones (2 frontal, 2 parietal, 2 temporal, 1 occipital) b. Facial muscles innervated by CN V and VII i. Muscles of the mouth 1. Orbicularis oris (close the lips) 2. Platysma (pull mandible down and back) 3. Masseter, pterygoid, and temporalis (mastication/chewing) ii. Muscles of the eyes 1. Orbicularis oculi (close the eyes) c. Temporal artery major artery of the face – passing anterior to the ear, over the temporal muscle, and onto the forehead d. 2 parotid glands, submandibular gland, and sublingual gland are salivary glands

e. Major nerves (Oh Once One Takes The Anatomy Final, Very Good Vacations Are Heavenly) (Some Say Marry Money But My Brother Says Big Brains Matter Most): i. Trigeminal nerve (CN V) 1. Motor: jaw open/clench, chew 2. Sensory: forehead, nose, oral and nasal mucosa, teeth, tongue, ear, midface 3. Three branches a. V1 (Ophthalmic – sensory only): sensations in your eyes, eyebrows, and forehead

b. V2 (Maxillary – sensory only): sensations in your cheek, side of your nose, under your eyes, top lip, and top teeth/gums c. V2 (Mandibular – mixed sensory and motor): sensation to lower lip, teeth, gums, side of the tongue, lower jaw and side of the head; motor for biting, chewing, swallowing

ii. Facial nerve (CN VII) 1. Motor: muscles of facial expression, close eyelids, labial speech 2. Sensory: taste (anterior 2/3 of tongue), pharynx 3. Parasympathetic: tears (lacrimal gland), saliva (submandibular and sublingual glands), sinuses iii. Glossopharyngeal (CN IX) 1. Motor: voluntary swallow and guttural speech 2. Sensory: nasopharynx, gag reflex, taste (posterior 1/3 of the tongue), chemoreceptors in carotid body 3. Parasympathetic: saliva (parotid gland) iv. Vagus (CN X) 1. Sensory

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v. Spinal Accessory (CN XI) 1. Motor: turn head, shrug shoulders vi. Hypoglossal (CN XII) 1. Motor: tongue for speech and swallowing vii. Spinal nerves (C2-4) 1. Sensory only Neck begins at the sternum and clavicles inferiorly and at the base of skull superiorly

i. Contains trachea, esophagus, internal/external jugular veins, common carotid, internal/external carotid arteries and thyroid g. Sternocleidomastoid (SCM) extends from upper sternum and medial third of the clavicle to the mastoid process h. Trapezius extends from the scapula, lateral third of the clavicle, and vertebrae to the occipital prominence i. Triangles of the neck (the carotid a. and internal/external jugular v. run deep to the SCM and not in either triangle) i. Anterior: medial border of the SCM, mandible, and the midline of the neck 1. Contains: thyroid gland, larynx, pharynx, lymph nodes, submandibular gland and fat ii. Posterior: trapezius, SCM and the clavicle 1. Contains: lymph nodes

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Thyroid i. Largest endocrine gland in the body ii. Produces thyroxine (T4) and triiodothyronine (T3) iii. Lateral lobes butterfly shaped and joined by an isthmus at the lower aspect iv. Isthmus lies across the trachea, below the cricoid cartilage 2. Infants, pregnant women and elderly a. In infants: posterior fontanel closes by 2 months and the anterior fontanel closes by 1215 months of age b. Pregnancy: a slight enlargement of the thyroid gland may be detectable on u/s i. Fetal thyroid gland is functional in the second trimester. Until then, mom is the source of thyroid hormone for the fetus and requires increased iodine intake.

There should be no thyroid growth during pregnancy AS LONG AS IODINE INTAKE IS ADEQUATE c. Elderly: T4 production and degradation gradually decrease; thyroid gland becomes more fibrotic 3. ROS a. Have you sustained any injuries to your head or neck? b. Do you have a history of headaches? c. Have you noticed lumps or swollen glands in your head or neck? d. Are you experiencing any neck stiffness? e. Have you ever had any problems with movement in your neck? f. Have you had any difficulty swallowing? 4. Common complaints of the head and neck a. Head/Neck Mass: i. When did you first notice the lump & where is it located? ii. Does it hurt? iii. Does the lump change in size? iv. Have you had any recent trauma or infections? (i.e.: ear or throat infections) v. Has there been hoarseness associated with the mass? vi. Is there a history of prior neck or thyroid gland radiation? b. Brain injury i. Anyone observe the injury/event ii. Consciousness immediately after and 5 min after the event iii. Assoc symptoms: head/neck pain, lacerations, change in vision, discharge from nose/ears, incontinence (fecal and urine), ability to move extremities c. Headache (Ha) i. OPQRST; gradual vs abrupt; location ii. Visual prodrome iii. Change in LOC iv. Assoc symptoms: n/v, photophobia, visual disturbances, increased lacrimation, tinnitus, paresthesias v. Precipitating factors: stress, fatigue, hunger, EtOH, allergies, menstruation (hormones), OCPs, caffeine d. Stiff neck vs. nuchal rigidity i. Injury ii. Experiencing any pain iii. Fevers, assoc ha, confusion, drowsiness, photophobia, cranial nerve deficits, seizures (all symptoms of possible meningitis) iv. Difficulty swallowing v. Limitation of movement or pain w/ movement vi. Vision or hearing changes 5. Physical examination of the Head a. Inspection of head and facial features (head should be still) i. Horizontal jerking or bobbing – tremor

ii. Nodding movement – aortic insufficiency (esp if nodding synchronized with the pulse) iii. Head tilted to one side possibly to favor a good eye or good ear, but can also signify torticollis (shortening or excessive contraction of the SCM) iv. Facies is an expression or appearance of the face and features of the head and neck that, when considered together, is characteristic of a clinical condition 1. Cushing syndrome: rounded or “moon shaped” face w/ thin, erythematous skin, “buffalo hump” 2. Hippocratic facies: sunken eyes, cheeks and temporal areas, sharp nose, dry/rough skin – terminal cancer 3. Myxedema facies: dull, puffy, yellowed skin, course/sparse hair, temporal loss of eyebrows, periorbital edema, prominent tongue 4. Butterfly rash of SLE: rash over malar surfaces and bridge of the nose 5. Acromegaly: coarse features, broadening of the nasal alae and prominent zygomatic arch 6. Hyperthyroid facies: fine, moist skin w/ fine hair, prominent eyes and lid retraction and startled expression (exophthalmos) 7. Bells palsy: unilateral facial paralysis (CN VII), eyelid unable to close completely, drooping lower eyelid and corner of the mouth and loss of nasolabial fold (suspect palsy when entire side of face is affected; suspect nerve weakness when only the lower portion of a side of the face is affected; only mouth involvement then suspect problem w/ trigeminal nerve) 8. Down Syndrome: depressed nasal bridge, epicanthal folds, mongoloid slant of the eyes, and low set ears 9. Hydrocephalus: enlarged head, thinning scalp w/ dilated scalp veins 10. Fetal alcohol syndrome: poorly formed philtrum, widespread eyes, w/ inner epicanthal folds and mild ptosis, hirsute forehead, short nose and relatively thin upper lip v. Skull for size, shape, symmetry, contour. Part hairs and inspect the scalp. Note any alopecia b. Palpation i. Of the skull in gentle, rotatory motion (should be symmetric and smooth) 1. Tenderness w/ indentation or depression may indicate skull fracture ii. Hair noting texture, color, and distribution 1. Coarse, dry, brittle hair assoc w/ hypothyroidism 2. Fine, silky hair assoc w/ hyperthyroidism (or familial) iii. Palpate the TMJ c. Percussion i. Not typically done expect when eval for hypocalcemia – percuss at the masseter and look for hyperactive masseteric reflex (Chvostek sign) d. Auscultation

i. Not typically performed expect when eval for vascular anomaly of the brain. Auscultate (with the bell) for bruits over the temporal arteries if the pt c/o headache and risk factors for temporal arteritis are present 6. Physical exam of the Neck (https://www.youtube.com/watch?v=fHR2Tw6DxEg) a. Inspection i. Symmetry of the SCM and trapezius, alignment of the trachea, fullness at the base of the neck and over salivary glands (esp parotid) 1. Note masses, webbing, excess skin folds a. Webbing, excessive posterior cervical skin, or unusually short neck my the assoc w/ chromosomal abnl (Turner syndrome) 2. Note jugular venous distention (JVD) or carotid artery prominence b. ROM of the neck i. Flexion, extension, lateral bend, rotation c. Auscultation of the neck for bruits (have pt hold breath while auscultating) i. Thyroid (bell and diaphragm) ii. Carotids (bell and diaphragm) iii. Bruits are heard as a result of blood flowing through a narrow or partially occluded artery d. Palpation i. Cervical spinous processes ii. Trapezius and SCM muscles bilaterally iii. Midline trachea iv. ID hyoid bone, trachea, larynx, thyroid and cricoid cartilage (should move under your fingers when the pt swallows v. Check for tracheal tug sign 1. Place index and thumb on either side of the trachea below the thyroid isthmus. A tugging sensation synchronized w/ the pulse is tracheal tug sign (Cardarelli sign – displace the thyroid cartilage to the pt’s left; or Oliver sign – apply upward pressure to the cricoid cartilage while pt stands and extends neck upward) and suggests aortic aneurysm vi. Lymph nodes 1. Preauricular; postauricular 2. Occipital; submandibular; submental 3. Tonsillar; superficial cervical; deep cervical; posterior cervical 4. Supraclavicular (have pt hold their breath); infraclavicular

7. Thyroid gland exam (remember your water for the check-off) *rarely palpable in a nl state

a. Inspection i. Ask pt to swallow to inspect size, symmetry, and contour as it moves w/ swallowing 1. An enlarged gland may only visible when viewing from the side of the pt b. Palpation i. Nodules and asymmetry more difficult to detect if pressing too hard so gentle palpation is necessary ii. Palpate for size, shape, configuration, consistency, tenderness and presence of any nodules 1. Estimation of thyroid size has been studied and found to be inaccurate (overestimation in cases of smaller thyroids and underestimation in cases of larger thyroids). Studies have found that lateral inspection is the most sensitive iii. Can palpate from in front of the patient or behind the patient (we teach posterior approach) iv. Steps to palpate the thyroid gland: 1. Pt should sit w/ SCM relaxed, neck flexed slightly forward and lateral toward the side being palpated 2. Ask the patient to take a sip of water in their mouth and hold it there until you are positioned and instruct them to swallow 3. Position two finger of each hand on the sides of the trachea just beneath the cricoid cartilage 4. Ask the patient to swallow , feeling for movement of the isthmus 5. With your right hand, displace the trachea to the left. 6. Palpate the left lobe of the thyroid with your left hand as the patient swallows 7. With your left hand, displace the trachea to the right 8. Palpate the right lobe of the thyroid with your right hand as the patient swallows v. Thyroid lobes should be small, smooth and free of nodules. It should rise freely with swallowing (right lobe 25% larger than the left lobe). Consistency should be pliable and firm 1. Coarse tissue or a gritty sensation suggests inflammation 2. Enlarged, tender thyroid indication thyroiditis 3. Nodules should be characterized by number, smooth/firm, regular/irregular 4. Auscultate an enlarged thyroid w/ the bell for vascular sounds a. In hypermetabolic states, the blood supply is increased and a vascular bruit may be heard (soft, rushing sound) vi. Thyroid goiter (abnl enlargement of thyroid gland) 1. Doesn’t mean malfunctioning, means there is a condition present causing abnl growth 2. Can occur in hypo, hyper, eu –thyroidism 8. Hypothyroidism

a. Primary: thyroid gland produces inadequate thyroid hormone (despite proper stimulation from the pituitary) b. Secondary: insufficient hormone secretion due to inadequate TSH from the pituitary gland or TRH (thyrotropin-releasing hormone) from the hypothalamus 9. Hyperthyroidism a. Excess thyroid hormone causes an increase in the metabolic rate b. If you understand the negative feedback loop you can figure out the labs involved in hypo and hyperthyroidism

System affected Temperature preference Weight Emotional state

Hair Skin Fingernails Eyes Neck Cardiac GI

Hyperthyroidism Cool (heat intolerance) Loss w/ good appetite Nervous/anxious, easily irritated, energetic, insomnia (fatigue) Fine w/ hair loss Warm, hyperpigmentation at pressure points Thin, tendency to break Bilat or unilat exophthalmos, lid retraction, double vision Goiter, pain over thyroid Tachycardic, palpitations Increased freq BM (diarrhea

Hypothyroidism Warm (cold intolerance) Gain w/ regular diet Lethargic, complacent, disinterested Coarse w/ tendency to break Coarse, dry, scaly Thick and brittle Puffiness in periorbital area No goiter No change Constipation

Menstrual Neuromuscular

rare) Scant flow, ?amenorrhea Increased weakness, esp in proximal muscles; hand tremors

Labs

TSH is low; FT4 and T3 is high

Menorrhagia (heavy menses) Lethargic, but good muscular strength Swelling of hands, face, legs TSH high; FT4/T3 low (primary) TSH/TRH low; FT4/T3 low (secondary)

10. Myxedema a. Skin and tissue disorder usually due to severe and prolonged hypothyroidism (metabolic rate decreasedaccumulation of hyaluronic acid and chondroitin sulfate in dermis; deposition of glycosaminoglycan in all organ systemsmucinous edema of facial features b. Pts c/o cognitive impairment, poor concentration, decreased short term memory, social withdrawal, depressed mood, constipation, muscle pain, hearing problems/deafness c. Objectively you’ll find coarse, thick skin, thickening of the nose, swollen lips, puffiness around the eyes, slowed speech, weight gain, thin, brittle hair with bald patches 11. Graves disease (overactive thyroid caused by autoimmune antibodies to TSH receptors) a. Pt c/o palpitations, heat intolerance, weight loss, fatigue, increased appetite b. Objectively you’ll find diffuse thyroid enlargement, exophthalmos, non-pitting edema (pretibial myxedema) 12. Hashimoto disease (underactive thyroid caused by autoimmune antibodies against the thyroid gland) a. Often causes hypothyroidism; progresses slowly b. Pt will c/o weight gain, nausea, fatigue c. Exam will reveal an enlarged, non-tender smooth thyroid gland...