Head and Neck
Content
HEAD
AND
NECK
ANATOMY AND PHYSIOLOGY - carotid artery and internal jugular vein lie deep and run parallel to sternocleidomastoid muscle along its medial margin - thyroid is largest endocrine gland DEVELOPMENTAL VARIATIONS A. INFANTS AND CHILDREN - anterior and posterior fontanels are membranous spaces formed where four cranial bones meet and intersect - spaces between cranial bones permit expansion of skull to accommodate brain growth B. PREGNANT WOMEN - number of changes in thyroid gland and thyroid hormones - physical signs of weight loss, tachycardia, eye signs, and bruit over thyroid are suggestive of hyperthyroidism C. OLDER ADULTS - thyroid gland becomes more fibrotic
I.
A.
SUBJECTIVE ASSESSMENT
LYMPHATIC 1. History of Present Illness - head injury = state of consciousness after injury, predisposing factors (seizure, poor vision, light-headness), associated symptoms, medications - headache = onset, duration, location, character (throbbing, pounding, boring, shocklike, dull, nagging), severity, pattern (worse in a.m. or p.m.) episodes, associated symptoms (nausea, vomiting, diarrhea) precipitating factors (fever, fatigue, stress, food additives), efforts to treat, medications - stiff neck = injury or strain, fever, bacterial or viral illness, character, predisposing factors (unilateral vision, hearing loss), efforts to treat, medications - thyroid problems = chg in temperature preference, swelling in neck, chg in emotional stability, increased prominence of eyes, tachycardia, chg in menstrual flow and/or bowel habits, medications - face = symmetry, lesions, masses, involuntary movement
2. Past Medical History - head trauma, radon or radium treatment, headaches, surgery for tumor, seizure disorder, thyroid dysfunction 3. Family History - headaches, thyroid dysfunction
4. Personal and Social History – employment (risk of head injury), stress, potential risk for injury (sports, unsafe environment), nutrition, use of alcohol and/or street drugs 5. Developmental Variations a. Infants and Children - prenatal history (mother’s use of drugs or alcohol) - birth history (vaginal, c-section, use of forceps) - unusual head shape - quality of head control - acute illness (diarrhea, vomiting, fever, stiff neck, irritability) - congenital anomalies b. Pregnant Women - presence of preexisting disease - history of pregnancy-induced hypertension - use of street drugs - medications c. Older Adults - dizziness with head or neck movement - weakness or impaired balance
II.
A. Head
OBJECTIVE ASSESSMENT
HEAD AND FACE 1. Inspection and Palpation (can start as soon as you see patient) of - inspect head position and facial features - horizontal jerking or bobbing motion may be associated with
tremors - head tilted or held to one side occurs with unilateral hearing or vision loss - facial features should be inspected for shape and symmetry with rest, movement, and expression - facial nerve paralysis is suspected when entire side of face is affected - facial nerve weakness is suspected when lower face is affected - tics (spasmodic muscular contractions of face, head, or neck) should be noted - note any edema, puffiness, coarsened features, prominent eyes, hirsutism, lack of expression, excessive perspiration, pallor, or pigmentation variations
- inspect skull for size, shape, and symmetry - note any hair loss pattern, lesions, scabs, tenderness, parasites, nits, or scaliness **If no abnormalities found, can document as “normocephalic” **Facial expressions are noted for pain, flat affect, mental capacity, truthfulness** 2. Palpation – scalp should move freely over skull, and no tenderness, swelling, or depressions on palpation are expected - note texture, color, distribution of hair - should be smooth, symmetrically distributed, no splitting or cracked ends - coarse, dry and brittle hair is associated with hypothyroidism - fine, silky hair is associated with hyperthyroidism - palpate temporal arteries and note course - note thickening, harness or tenderness which may be associated with temporal arteritis - inspect for any asymmetry or enlargement of salivary glands - if noted, palpate for discrete enlargement, noting if it is fixed or movable, soft or hard, tender or nontender 3. 4. Percussion- not routinely performed
Auscultation – not routinely performed - listen for bruits over skull and eyes - use bell of stethoscope over temporal region, over eyes, and below occiput B. NECK 1. Inspection – inspect while in usual anatomic position, slight hyperextension, and as patient swallows - look for bilateral symmetry, alignment of trachea, landmarks of anterior and posterior triangles, and any subtle fullness at base of neck - observe for any distention of jugular vein or prominence of carotid arteries - marked edema of neck is associated with local infections - mass filling base of neck or visible thyroid tissue that glides upward when patient swallows may indicate an enlarged thyroid - evaluate ROM by asking pt to flex, extend, rotate, and laterally turn head and neck - movement should be smooth and painless and should not cause dizziness 2. Palpation – palpate trachea for midline position
- hyoid bone, thyroid and cricoid cartilages should be smooth, nontender and should move under finger when pt swallows - examination of thyroid gland involves inspection, palpation, and auscultation - ask pt to hyperextend head so that neck skin is tightened - note any asymmetry - after offering pt sip of water and positioning again in hyperextended state, ask pt to swallow - enlarged thyroid gland may be visible (also may be visible only from lateral aspect) - palpate thyroid for size, shape, configuration, consistency, tenderness, and presence of any nodules - pt should be positioned to relax, with neck flexed slightly forward and laterally toward side being examined - to facilitate swallowing, give pt a cup of water - thyroid lobes, if felt, should be small, smooth, and free of nodules - should rise freely with swallowing - consistency should be firm yet pliable - coarse tissue or gritty sensation implies inflammatory process has been present - if nodules are present, they are characterized by number, smooth or irregular, soft or hard, and tenderness indicates thyroiditis - if gland is enlarges, auscultate with bell to hear vascular bruit (soft, rushing sound) 3. or swellings - inspect scalp for scaling and crusting, dilated scalp veins, presence of excessive hair or unusual hairline - birth trauma may cause swelling of scalp caput succedaneum - subcutaneous edema over presenting part of head at delivery - most common form of birth trauma - affected part feels soft, margins are poorly defined, and edema, generally, goes away in a few days cephalhematoma – subperiosteal collection of blood and bound by suture lines - commonly found in parietal region, may not be immediately obvious at birth Developmental Variations a. Infants - inspect for symmetry of shape, noting any prominent bulges
- firm and edges are well defined; does not cross suture lines - may liquefy and become fluctuant on palpation - bossing (bulging of skull) of frontal areas is associated with prematurity and rickets - in other areas may indicate cranial defects or intracranial masses - inspect face for spacing of features, symmetry, paralysis, skin color, and texture - note any jerking, tremors, or inability to move head in one direction - inspect neck for symmetry, size, and shape - note presence of edema, distended neck veins, pulsations, masses, webbing, or excessive posterior cervical skin - marked edema may indicate localized infection - nuchal rigidity (resistance to flexion) is associated with meningeal irritation - palpate infant’s head, identifying suture lines and fontanels (give important clues as to what is going on inside the body) - note any tenderness over scalp - fontanels may be small or not palpable at birth - 3rd fontanel located between anterior and posterior fontanel may be an expected variant but is common in infants with Down Syndrome - any palpable ridges in addition to expected may indicate fractures - palpate anterior fontanel for bulging or depression - bulging fontanel feels tense and indicates infection or increased intracranial pressure - cannot assume fontanel that is not bulging is free of meningitis - palpate scalp firmly above and behind ears to detect craniotabes (softening of outer table of skull) - indication is a snapping sensation, similar to bounce of ping-pong ball
III.
A.
COMMON ABNORMALITIES
HEADACHE- most common complaint and one of the most self-medicated - not always benign - history of insistent, severe, and recurrents must always be given attention - sometimes underlying cause is life threatening (brain tumor) B. TORTICOLLIS – wryneck - result of injury during delivery
- head is tilted and twisted toward sternocleidomastoid muscle - hematoma may be palpated shortly after birth - firm, fibrous mass - can occur in older children and adults as a result of trauma, muscle spasms, viral infection, or drug ingestion C. SALIVARY GLAND TUMOR – may arise in any salivary gland, but most common in parotid D. HYPOTHYROIDISM / HYPERTHYROIDISM - thyroid hormone influences metabolism of most cells in body - overabundance or paucity can cause symptoms affecting many body systems System / Structure Affected
Constitutional (temp. preference, wt., emotional state) Hair Skin Fingernails Eyes Neck Cardiac Gastrointestinal / Menstrual Neuromuscular
Hyperthyroidism
Cool climate, wt. loss, nervous, easily irritated, highly energetic Fine, w/loss; failure to hold perm. wave Warm, fine, hyperpigment. at pressure pts. Thin, w/tendency to break; show onycholysis Bilateral/Unilateral proptosis, lid retraction, dbl vision Goiter, chg in shirt neck size, pain over thyroid Tachycardia., dysrhythmia, palpitations Increased frequency of B.M.s; diarrhea rare/ Scant flow Increasing weakness, esp. in proximal muscles
Hypothyroidism
Warm climate, wt gain, lethargic, complacent, disinterested Coarse, w/ tendency to break Coarse, scaling, dry Thick Puffiness in periorbital region No goiter No chg noted Constipation / Menorrhagia Lethargic, but good muscular strength
E. MYXEDEMA – adult onset hypothyroidism associated with decreased metabolic rate - deposition of glycosaminoglycan in all organ systems leads to mucinous edema of facial features F. GRAVES DISEASE – thought to be autoimmune - more common in women during 3rd and 4th decades of life - multiple systems affected, often characterized by diffuse thyroid enlargement, hyperthyroidism, ophthalmologic, dermatologic, constitutional, menstrual, and musculoskeletal pathologic conditions - pregnancy can make diagnosis more difficult - presence of goiter may not be specific - presence of wt. loss, marked tachy, eye signs, bruit over thyroid are suggestive
G. ENCEPHALOCELE – protrusion of nervous tissue through defect in skull may occur any place on scalp
AND
NECK
ANATOMY AND PHYSIOLOGY - carotid artery and internal jugular vein lie deep and run parallel to sternocleidomastoid muscle along its medial margin - thyroid is largest endocrine gland DEVELOPMENTAL VARIATIONS A. INFANTS AND CHILDREN - anterior and posterior fontanels are membranous spaces formed where four cranial bones meet and intersect - spaces between cranial bones permit expansion of skull to accommodate brain growth B. PREGNANT WOMEN - number of changes in thyroid gland and thyroid hormones - physical signs of weight loss, tachycardia, eye signs, and bruit over thyroid are suggestive of hyperthyroidism C. OLDER ADULTS - thyroid gland becomes more fibrotic
I.
A.
SUBJECTIVE ASSESSMENT
LYMPHATIC 1. History of Present Illness - head injury = state of consciousness after injury, predisposing factors (seizure, poor vision, light-headness), associated symptoms, medications - headache = onset, duration, location, character (throbbing, pounding, boring, shocklike, dull, nagging), severity, pattern (worse in a.m. or p.m.) episodes, associated symptoms (nausea, vomiting, diarrhea) precipitating factors (fever, fatigue, stress, food additives), efforts to treat, medications - stiff neck = injury or strain, fever, bacterial or viral illness, character, predisposing factors (unilateral vision, hearing loss), efforts to treat, medications - thyroid problems = chg in temperature preference, swelling in neck, chg in emotional stability, increased prominence of eyes, tachycardia, chg in menstrual flow and/or bowel habits, medications - face = symmetry, lesions, masses, involuntary movement
2. Past Medical History - head trauma, radon or radium treatment, headaches, surgery for tumor, seizure disorder, thyroid dysfunction 3. Family History - headaches, thyroid dysfunction
4. Personal and Social History – employment (risk of head injury), stress, potential risk for injury (sports, unsafe environment), nutrition, use of alcohol and/or street drugs 5. Developmental Variations a. Infants and Children - prenatal history (mother’s use of drugs or alcohol) - birth history (vaginal, c-section, use of forceps) - unusual head shape - quality of head control - acute illness (diarrhea, vomiting, fever, stiff neck, irritability) - congenital anomalies b. Pregnant Women - presence of preexisting disease - history of pregnancy-induced hypertension - use of street drugs - medications c. Older Adults - dizziness with head or neck movement - weakness or impaired balance
II.
A. Head
OBJECTIVE ASSESSMENT
HEAD AND FACE 1. Inspection and Palpation (can start as soon as you see patient) of - inspect head position and facial features - horizontal jerking or bobbing motion may be associated with
tremors - head tilted or held to one side occurs with unilateral hearing or vision loss - facial features should be inspected for shape and symmetry with rest, movement, and expression - facial nerve paralysis is suspected when entire side of face is affected - facial nerve weakness is suspected when lower face is affected - tics (spasmodic muscular contractions of face, head, or neck) should be noted - note any edema, puffiness, coarsened features, prominent eyes, hirsutism, lack of expression, excessive perspiration, pallor, or pigmentation variations
- inspect skull for size, shape, and symmetry - note any hair loss pattern, lesions, scabs, tenderness, parasites, nits, or scaliness **If no abnormalities found, can document as “normocephalic” **Facial expressions are noted for pain, flat affect, mental capacity, truthfulness** 2. Palpation – scalp should move freely over skull, and no tenderness, swelling, or depressions on palpation are expected - note texture, color, distribution of hair - should be smooth, symmetrically distributed, no splitting or cracked ends - coarse, dry and brittle hair is associated with hypothyroidism - fine, silky hair is associated with hyperthyroidism - palpate temporal arteries and note course - note thickening, harness or tenderness which may be associated with temporal arteritis - inspect for any asymmetry or enlargement of salivary glands - if noted, palpate for discrete enlargement, noting if it is fixed or movable, soft or hard, tender or nontender 3. 4. Percussion- not routinely performed
Auscultation – not routinely performed - listen for bruits over skull and eyes - use bell of stethoscope over temporal region, over eyes, and below occiput B. NECK 1. Inspection – inspect while in usual anatomic position, slight hyperextension, and as patient swallows - look for bilateral symmetry, alignment of trachea, landmarks of anterior and posterior triangles, and any subtle fullness at base of neck - observe for any distention of jugular vein or prominence of carotid arteries - marked edema of neck is associated with local infections - mass filling base of neck or visible thyroid tissue that glides upward when patient swallows may indicate an enlarged thyroid - evaluate ROM by asking pt to flex, extend, rotate, and laterally turn head and neck - movement should be smooth and painless and should not cause dizziness 2. Palpation – palpate trachea for midline position
- hyoid bone, thyroid and cricoid cartilages should be smooth, nontender and should move under finger when pt swallows - examination of thyroid gland involves inspection, palpation, and auscultation - ask pt to hyperextend head so that neck skin is tightened - note any asymmetry - after offering pt sip of water and positioning again in hyperextended state, ask pt to swallow - enlarged thyroid gland may be visible (also may be visible only from lateral aspect) - palpate thyroid for size, shape, configuration, consistency, tenderness, and presence of any nodules - pt should be positioned to relax, with neck flexed slightly forward and laterally toward side being examined - to facilitate swallowing, give pt a cup of water - thyroid lobes, if felt, should be small, smooth, and free of nodules - should rise freely with swallowing - consistency should be firm yet pliable - coarse tissue or gritty sensation implies inflammatory process has been present - if nodules are present, they are characterized by number, smooth or irregular, soft or hard, and tenderness indicates thyroiditis - if gland is enlarges, auscultate with bell to hear vascular bruit (soft, rushing sound) 3. or swellings - inspect scalp for scaling and crusting, dilated scalp veins, presence of excessive hair or unusual hairline - birth trauma may cause swelling of scalp caput succedaneum - subcutaneous edema over presenting part of head at delivery - most common form of birth trauma - affected part feels soft, margins are poorly defined, and edema, generally, goes away in a few days cephalhematoma – subperiosteal collection of blood and bound by suture lines - commonly found in parietal region, may not be immediately obvious at birth Developmental Variations a. Infants - inspect for symmetry of shape, noting any prominent bulges
- firm and edges are well defined; does not cross suture lines - may liquefy and become fluctuant on palpation - bossing (bulging of skull) of frontal areas is associated with prematurity and rickets - in other areas may indicate cranial defects or intracranial masses - inspect face for spacing of features, symmetry, paralysis, skin color, and texture - note any jerking, tremors, or inability to move head in one direction - inspect neck for symmetry, size, and shape - note presence of edema, distended neck veins, pulsations, masses, webbing, or excessive posterior cervical skin - marked edema may indicate localized infection - nuchal rigidity (resistance to flexion) is associated with meningeal irritation - palpate infant’s head, identifying suture lines and fontanels (give important clues as to what is going on inside the body) - note any tenderness over scalp - fontanels may be small or not palpable at birth - 3rd fontanel located between anterior and posterior fontanel may be an expected variant but is common in infants with Down Syndrome - any palpable ridges in addition to expected may indicate fractures - palpate anterior fontanel for bulging or depression - bulging fontanel feels tense and indicates infection or increased intracranial pressure - cannot assume fontanel that is not bulging is free of meningitis - palpate scalp firmly above and behind ears to detect craniotabes (softening of outer table of skull) - indication is a snapping sensation, similar to bounce of ping-pong ball
III.
A.
COMMON ABNORMALITIES
HEADACHE- most common complaint and one of the most self-medicated - not always benign - history of insistent, severe, and recurrents must always be given attention - sometimes underlying cause is life threatening (brain tumor) B. TORTICOLLIS – wryneck - result of injury during delivery
- head is tilted and twisted toward sternocleidomastoid muscle - hematoma may be palpated shortly after birth - firm, fibrous mass - can occur in older children and adults as a result of trauma, muscle spasms, viral infection, or drug ingestion C. SALIVARY GLAND TUMOR – may arise in any salivary gland, but most common in parotid D. HYPOTHYROIDISM / HYPERTHYROIDISM - thyroid hormone influences metabolism of most cells in body - overabundance or paucity can cause symptoms affecting many body systems System / Structure Affected
Constitutional (temp. preference, wt., emotional state) Hair Skin Fingernails Eyes Neck Cardiac Gastrointestinal / Menstrual Neuromuscular
Hyperthyroidism
Cool climate, wt. loss, nervous, easily irritated, highly energetic Fine, w/loss; failure to hold perm. wave Warm, fine, hyperpigment. at pressure pts. Thin, w/tendency to break; show onycholysis Bilateral/Unilateral proptosis, lid retraction, dbl vision Goiter, chg in shirt neck size, pain over thyroid Tachycardia., dysrhythmia, palpitations Increased frequency of B.M.s; diarrhea rare/ Scant flow Increasing weakness, esp. in proximal muscles
Hypothyroidism
Warm climate, wt gain, lethargic, complacent, disinterested Coarse, w/ tendency to break Coarse, scaling, dry Thick Puffiness in periorbital region No goiter No chg noted Constipation / Menorrhagia Lethargic, but good muscular strength
E. MYXEDEMA – adult onset hypothyroidism associated with decreased metabolic rate - deposition of glycosaminoglycan in all organ systems leads to mucinous edema of facial features F. GRAVES DISEASE – thought to be autoimmune - more common in women during 3rd and 4th decades of life - multiple systems affected, often characterized by diffuse thyroid enlargement, hyperthyroidism, ophthalmologic, dermatologic, constitutional, menstrual, and musculoskeletal pathologic conditions - pregnancy can make diagnosis more difficult - presence of goiter may not be specific - presence of wt. loss, marked tachy, eye signs, bruit over thyroid are suggestive
G. ENCEPHALOCELE – protrusion of nervous tissue through defect in skull may occur any place on scalp
