Ch 10 Head & Neck (Seidel)

Cranial Bruits

* common in children up to 5 years OR in children with anemia. * after 5 years old, may suggest vascular anomalies or increased ICP.

Brachiocephaly

* common in preterm infants; long, narrow heads because their soft cranial bones become flattened with positioning and the weight of the head.

Seven bones comprise the SKULL

(2) Frontal, (2) Parietal, (2) Temporal, (1) Occipital

Clavicles

* "crunch" is indicative of fracture @ birth.

INFANTS

* 7 cranial bones are soft & separated by Sagital, Coronal, & Lambdoid sutures. * Suture ossification begins after brain growth complete ~ 6 yo & finished in adulthood. * Anterior & Posterior fontanels: membranous space formed where 4 cranial bones meet. This space permits expansion for brain growth. Posterior ossification @ ~ 2 months & Anterior @ ~ 12-15 months. * Vaginal birth -> molding of skull (cranial bones overlap) -> should regain appropriate size & shape within days.

RELATED HISTORY: Stiff Neck

* ?? injury, strain, traumatic brain injury, swelling. * ?? fever, headache, s/s of meningitis. * ?? character with movement: limitation/ pain/ pain relieved/ continuous or cramping/ radiation pattern to arms/shoulders/hands/back. * Predisposing factors: unilateral vision or hearing loss; work position. * efforts to treat * medications: analgesics, muscle relaxants

Temporal Artery

* MAJOR accessible artery of the face. * passes just anterior to the ear, over the temporal muscle, & onto the forehead

Hydrocephalus

* abnormal formation, flow or absorption of CSF that -> increase CSF volume in the ventricles of the brain. * normal flow CSF: choroid plexus -> lateral ventricle -> interventricular foramen of Monro -> 3rd ventricle -> aqueduct of Sylvius -> 4th ventricle -> 2nd lateral foramina of Luschka & medial foramen of Magendie -> subarachnoid space -> arachnoid granulations -> dural sinus -> venous circulation. * can arise from: congenital malformations, congenital infections (toxoplasmosis), acquired abnormalities (intracranial mass or hemorrhage, meningitis, & trauma) SUBJECTIVE DATA: poor feeding, irritability, decreased activity, vomiting. OBJECTIVE DATA: head enlargement, suture separation, dilated scalp veins, tense anterior fontanelle, sunsetting sign, increased tone, Macewen sign

Scotoma

* an abnormal area of absent or depressed vision surrounded by an area of normal vision.

nystagmus

* an involuntary, rhythmic oscillation of the eyeballs; may be lateral, vertical, or rotary.

SKULL: Inspection

* assess size, shape, symmetry, scalp, esp. areas behind ears, @ hairline, & crown. * note any alopecia; hair loss in children is commonly tinea capitis.

Salivary Glands

* asymmetry or enlargement * fixed/movable, soft/hard, tender/nontender. * enlarged or tender glands may = bacterial or viral infection or stone blocking saliva flow. * discrete nodule may = cyst or tumor (benign or malignant) * attempt to express material through salivary ducts as you press on glands. ABNORMALITIES OBJECTIVE DATA: (most commonly parotid) benign tumors = smooth, malignant = irregular. Facial weakness, fixation of lump, sensory loss, ulceration. ABNORMALITIES SUBJECTIVE DATA: slow growing painless lumps in front of ear or under jaw. Difficulty opening mouth & tongue numbness or weakness.

Hashimoto disease

* autoimmune antibodies against thyroid gland. * causes hypothyroidism. * MORE COMMON in children & women between 30-50 years. SUBJECTIVE DATA: progresses slowly over years, s/s of hypothyroidism, wt gain, nausea, fatigue. OBJECTIVE DATA: enlarged nontender smooth thyroid.

Graves disease

* autoimmune antibodies to thyroid-stimulating hormone receptor -> overactive thyroid. * MORE COMMON in women during 3rd & 4th decade. SUBJECTIVE DATA: same s/s as hyperthyroidism. OBJECTIVE DATA: diffuse thyroid enlargement, w/ exophthalmos. Dermatologic, constitutional, menstrual & musculoskeletal abnormalities, nonpitting edema (pretibial myxedema).

Hemianopia

* blindness in one half of the visual field of one or both eyes.

RELATED HISTORY: Past Medical History

* brain injury, subdural hematoma, LP, radiation tx of head/neck, HA, tumor/goiter sx, seizure disorder, thyroid dysfunction.

Bossing

* bulging of the skull frontal areas) associated with thalassemia, prematurity, Paget disease, & rickets. (bulging in other areas of the skull may indicate cranial defects or intracranial masses)

RELATED HISTORY: Thyroid Problems

* change in temp preference. * neck swelling: difficulty swallowing, redness, pain with touch/swallowing/hyperextension, difficulty buttoning shirt. * change in texture of hair, skin, nails, or increased pigmentation of skin @ pressure points. * change in: mood/ energy/ irritability/ nervousness/ lethargy/ disinterest menses/ bowel habits. * exophthalmos (increased prominence of eyes), periorbital swelling, blurred/double vision. * tachycardia, palpitations

microcephaly

* circumference of head is smaller than normal, brain has not developed properly or has stopped growing. * present @ birth OR develops in first few years of life. * causes: congenital infections, neuroanatomic abnormalities (cerebral dysgenesis, craniostenosis) SUBJECTIVE DATA: associated with intellectual disability & failure of brain to develop normally OBJECTIVE DATA: HC is 2-3 standard deviations below mean for age.

Branchial Cleft Cyst

* congenital lesion formed by incomplete invilution of branchial cleft. * epithelium-lined cyst with or w/o a sinus tract to overlying skin. SUBJECTIVE DATA: solitary, painless in lateral neck. Intermittent swelling/tenderness. Discharge if associated with sinus tract. OBJECTIVE DATA: oval, movable smooth, non-tender, fluctuations mass along anteromedial border of sternocleidomastoid muscle. Asymptomatic. Tenderness & erythema if infected.

RELATED HISTORY: Traumatic Brain Injury

* consciousness after injury: immediately & @ 5 minutes. Duration of unconsciousness; combative, confused, alert, dazed. * ?? predisposing factors: seizure, hypoglycemia, poor vision, light-headedness, syncope. * associated symptoms: head/neck pain, lacerations, tenderness, change in breathing, blurred/double vision, nose/ear discharge, N/V, urinary/fecal incontinence, ability to move all extremities.

Thyroglossal Duct Cyst

* cystic mass in the neck. * remnant of fetal development that rises from foramen cecum. Any part can persist -> sinus, fistula, or cyst. SUBJECTIVE DATA: tenderness, sewell ing @ ML of neck, difficulty swallowing or breathing. OBJECTIVE DATA: freely movable custom mass, moves upwards with tongue protrusion & swallowing, may have small opening in skin with mucus drainage.

CHILD: Percussion Macewen Sign

* direct percussion of the skull with 1 finger * percussion near the junction of the frontal, temporal & parietal bones -> a strong resonant sound with hydrocephalus or brain abscess. * resonant sound IS expected when fontanels are open & may indicate increased ICP after fontanel closure.

RELATED HISTORY: Elderly

* dizziness or vertigo with head/neck movement * weakness or impaired balance * increasing r/o falling & head injury

papilledema

* edema and inflammation of the optic nerve at its point of entrance into the retina.

Thyroid Gland

* examination includes inspection, palpation & auscultation with gentle extension of neck. * swallowing allows visualization of size, symmetry & contour; have cup of water for multiple swallows & proper examination * enlarged gland may only be visible from lateral aspect which is most sensitive for presence of goiter. (if not thyroid not visible from side = rules out goiter). * gentle palpation required for nodule & asymmetry detection. * palpate for size, shape, configuration, consistency, tenderness, & nodules. * can be palpated from in front or behind the pt. * thyroid gland moves with swallowing, fat mimicking a goiter does not.

Facies

* expression or appearance of face, head, & neck that is characteristic of a clinical condition or syndrome.

encephalocele

* failure of the anterior neural tube to close completely during fetal development. Brain is actually outside the skull in a membrane covered sack. * due to genetic (familial hx of spina bifida), toxic or infectious reasons. SUBJECTIVE DATA: only visible by ultrasound prior to birth or at delivery. OBJECTIVE DATA: visible sac of tissue protruding through skull. craniofacial abnormalities or other malformations, hydrocephalus.

PREGNANT WOMEN: Thyroid

* fetal thyroid becomes functional 2nd trimester. * before 2nd trimester, mother is the thyroid hormone source & she requires increased iodine intake. * adequate iodine intake -> no change in thyroid size upon physical exam; however, slight enlargement may be detected by ultrasound. * thyroid hypertrophy is caused by hyperplasia of glandular tissue & increased vascularity which may -> thyroid bruit. * goiter is abnormal. * diagnosis of hyperthyroidism is difficult during pg; suggested with wt loss, tachycardia, & bruit over thyroid. Confirm dx with serum TSH & free T4.

Plagiocephaly

* flattening or asymmetry of the head d/t premature fusion of one side or both sides via coronal or lambdoidal sutures. * positional plagiocephaly: common in torticollis

INFANT: Palpation

* for tenderness * sutures feel ridge-like & may be prominent with overriding sutures following vag delivery (parents may need reassurance that normal shape will resume within 1 week). * fontanels may be small or non-palpable. * "Third Fontanel" (mastoid fontanel) may be an expected variant but is common in Down Syndrome. * palpable ridges in addition to the expected suture lines may indicate skull fracture.

proptosis

* forward protrusion of the eye.

Bony Structure of the FACE

* fused frontal, nasal, zygomatic, ethmoid, lacrimal, sphenoid, & maxillary bones. * movable mandible.

FACE: inspection

* inspect facial features: eyelids, eyebrows, palpebral fissures, nasolabial folds, mouth. * assess shape & symmetry with rest, movement, & expression this partially tests integrity of CN V & CN VII. * note changes in shape or unusual features: edema, bruising, coarsened features, exophthalmos, hirsutism, lack of expression, excessive perspiration, pallor, or pigmentation.

Face

* inspect for spacing of features, symmetry, paralysis, skin color, & texture. * uterine positioning can -> facial asymmerty

NECK: Inspection

* inspect in usual anatomic position: slight hyperextension & as pt swallows. Assess for bilat symmetry of sternocleidomastoid & trapezius muscles, alignment of trachea, landmarks of anterior & posterior triangles. * note masses, asymmetry, webbing/excess skinfolds/unusual shortness (associated with chromosomal anomalies). * assess for jugular vein distention or prominence of carotid arteries. * marked edema may = local infection (cervical lymphadenitis. * mass filling base of neck OR visible thyroid tissue that glides upwards when pt swallows may = enlarged thyroid. * assess ROM, mob=movement should be smooth & painless without dizziness.

SKULL: Auscultation

* intracranial bruits common in childhood, uncommon in neonates * rarely: a bruit or blowing sound over the orbit with pts that have developed diplopia may suggest expanding cerebral aneurysm. * suspected vascualr anomaly: use the bell of stethoscope & listen over temporal region, over eyes & below occiput; if bruit heard, suggests vascular anomoly & associated with temporal arteritis

Cephalhematoma

* subperiosteal collection of blood & bound by suture lines & most often found in parietal region. * may not be immediately obvious @ birth. * firm with well defined edges & does not cross suture lines. * may liquefy & become fluctant as it ages.

Thyroid Gland

* largest endocrine gland. * produces Thyroxine (T4) & Triiodothyronine (T3). * two lateral lobes joined by isthmus at lower aspect & largely covered by sternocleidomastiod muscles. * isthmus lies across the trachea & below cricoid cartilage. * pyramidal lobe present in 1/3 of population. * broadest dimension is ~ 4cm, R lobe is often 25% larger than L. * coarse tissue or gritty sensation suggests inflammatory process; count nodules & note smooth or irregular, soft/hard. * enlarged & tender = thyroiditis * if enlarged, auscultate with bell for vascular sounds; hypermetabolic state = increased blood supply -> vascular bruit.

CHILD: Thyroid

* may be palpable. * using same technique as adult palpation, note size, shape, position, mobility, & tenderness. * enlarged, tender thyroid may = Thyroiditis.

INFANT: Inspection

* measure & compare with expectations & previous points on growth chart. * inspect from all angles (esp. from above) for symmetry & shape; note bulges or depressions. * inspect for scaling, crusting, birthmarks, lesions, dilated scalp veins, excessive hair or unusual hairline. * dilated veins & increasing head circumference (faster than expected) may = increased ICP.

Fontanels

* measure anteroposterior & lateral dimensions. * anterior fontanel diameter @ < 6 mons should be < 4-5 cm & close at ~ 12-15 months. * palpate when infant in supported sitting position. * bulging + marked pulsations may = increased ICP from a space-occupying mass or meningitis.

Tics

* note any spasmodic muscular contractions of the face/head/neck. * may be associated with pressure or degenerative changes of facial nerves, Tourette Syndrome, or psychogenic in origin.

Neck

* note edema (marked: localized infection), distended neck veins, pulsations, masses, webbing, excess nuchal skin. * cystic mass high in the neck may = thyroglossal duct cust or branchial cleft cyst * mass over clavicle that changes size with crying or respiration may = cystic hygroma.

Sternocleidomastoid muscle

* note tone & any masses. * a mass on the lower 1/3 of the muscle may = a hematoma.

Meningeal Irritation

* nuchal rigidity or resistance to flexion

SKULL: Percussion

* only used to assess for the Chvostek sign (percussion on the masseter mucscle = hyperactive masseteric reflex) with hypercalcemia.

HYPERthyroidism

* overactive thyroid -> increase in metabolic rate. * increased total body heat production & heart contractility & rate, & vasodilation. * Plummer disease: multinodular goiter. SUBJECTIVE DATA: wt loss, tachycardia, diarrhea, heat sensitivity. OBJECTIVE DATA: normal size thyroid, goiter, or nodule(s). fine hair, brittle nails, proptosis, tachycardia

SKULL: Palpation

* palpate in a gentle rotary movement from front to back, bones should be indistinguishable after 6 months old, ridge of sagital suture may be felt. * scalp should move freely over skull without tenderness, swelling, or depressions. * indentation or depression may = skull fracture.

Temporomandibular joint

* palpate joint space with mouth open; clicking or snapping not unusual. * dysfunction =pain, crepitus, locking, or popping.

Craniosynostosis

* premature closure of one or more cranial sutures before brain growth complete -> misshapen skull. * involved sutures determine shape of head. SUBJECTIVE DATA: abnormally shaped skull, usually not accompanied with mental retardation. OBJECTIVE DATA: skull growth restricted perpendicular to fused suture. If multiple sutures fuse -> increased ICP

RELATED HISTORY: Infants

* prenatal hx: maternal drug use, uterine abnormalities, hyperthyroid tx. * birth hx: birth order, delivery type, delivery presentation & difficulty, forceps/assist device. * unusual head shape. * strength of head control. * acute illness: D/V, fever, limited neck movement, irritability. * congenital abnormalities. * neonatal screening for congenital hypothyroidism.

ELDERLY

* rate of T4 production & degradation gradually decreases & thyroid gland becomes more fibrotic = nodular or irregular to palpation.

Torticollis (Wry Neck)

* shortening or excessive contraction of the sternocleidomastoid muscle. * result of birth trauma or intrauterine malposition. * acquired torticollis is result of tumors, trauma, CN IV palsy, muscle spasms, infection, or drug ingestion. * SUBJECTIVE DATA: circumstances surrounding birth, stiff neck, decreased neck ROM, possible vision problem. OBJECTIVE DATA: head tilted & twisted toward the affected sternocleidomastoid muscle with chin elevated & turned toward the opposite side. Possible plapable hematoma shortly after birth & w/in 2-3 weeks. Firm, fibrous mass may be felt in the muscle.

Myxedema

* skin & tissue disorder d/t severe prolonged HYPOthyroidism. * decrease metabolic rate, accumulation of hyaluronic acid & chondroitin sulfate in the dermis. * deposition of glycosaminoglycan in all organ systems -> mucinous edema of facial features. SUBJECTIVE DATA: cognitive impairment, slowed mentation, poor concentration, decreased short term memory, socially withdrawn, psychomotor retardation, depressed mood, apathy. Constipation, muscle pains, hearing problems, deafness. OBJECTIVE DATA: coarse, thick skin, thickening nose, swollen lips, puffiness around eyes, slow speech, mental dullness, lethargy, mental problems, wt gain, brittle hair w/ bald patches.

Hair

* smooth & symmetrically distributed * coarse, dry & brittle may = Hypothyroidism or familial

Craniotabes

* softening of the outer table of the skull. * palpate scalp firmly above & behind ears for a snapping sensation (similar to the feeling of pressing a ping-pong ball). * may be associated with prematurity, rickets, hydrocephalus, marasmus, syphilis or thalassemia.

HEAD: inspection

* start with head position; head should be upright & still. * horizontal jerking or bobbing may be tremor. Nodding (esp. synchronized with pulse) may be aortic insufficiency. * head tilted to one side may = unilateral hearing or vision loss; also torticollis.

Caput succedaneum

* subcutaneous edema over presenting part of head; resolves in a few days. * MOST common birth trauma of scalp & usually occurs over occiput & crosses suture lines. * soft with poorly defined margins.

CHILDREN & ADOLESCENTS

* subtle facial appearance changes throughout childhood. * male adolescent: nose & thyroid cartilage enlarge & facial hair develops (1st upper lip -> cheeks -> lower lip -> chin).

facial asymmetry

* suspect facial nerve paralysis when entire side of face is affected. * suspect facial nerve weakness when only lower face is affected. * suspect a problem with trigeminal nerve if only the mouth is involved.

Trachea

* thyroid difficult to palpate on infant unless enlarged. * goiter may cause RD & results from intrauterine thyroid hormone deprivation.

NECK: Palpation

* trachea for ML position; place thumb along each side @ lower portion of neck. * compare space between trachea & sternocleidomastoid muscle bilat; unequal space = tracheal displacement from ML & may = mass or pathologic condition in the chest. * Hyoid bone/thyroid/cricoid cartilages: should be smooth & nontneder, move under your finger when pt swallows, & cartilaginous rings should be distinct & nontender. * plapate paravertebral muscles & posterior spinous processes for tenderness in evaluation of stiff neck. * extend neck, place index finger & thumb on each side of trachea below thyroid isthmus; tugging sensation synchronous with pulse = tracheal tug sign (Cardarelli or Oliver sign) suggests aortic aneurysm.

HYPOthyroidism

* underactive thyroid * PRIMARY: insufficient amts of thyroid hormone from thyroid. * SECONDARY: insufficient thyroid hormone d/t inadequate TSH from pituitary or TRH from hypothalamus. * MORE COMMON than Hyperthyroidism. SUBJECTIVE DATA: wt gain, constipation, fatigue, & cold intolerance. OBJECTIVE DATA: normal size thyroid, goiter or nodule.

Head

* unusual contour may be related to premature/irregular closing of sutures. * observe infant's head control, position, & movement. Note any jerking, tremors, or inability to move head in one direction.

ELDERLY: ROM of Neck

* use caution & have pt perform each movement separately; note pain, crepitus, dizziness, jerkiness, or limitation of movement

Transillumination

* used with suspected intracranial lesions or rapidly increasing head circumference. * performed less often due to availability of CT. * completely dark room, wait a few minutes for eyes to adjust. * observe the ring of illumination through the scalp & skull around the light source; note any asymmetry. * expect =/< 2cm beyond the rim of the light source in all regions of the head EXCEPT occiput (ring should =/< 1cm). Illumination beyond these parameters suggests excess fluid or decreased brain tissue

ELDERLY: facies

* varies with nutritional status; eyes may appear sunken with soft bulges underneath. Eyelids may appear wrinkled & hang loose.

RELATED HISTORY: Pregnant Women

* weeks gestation or postpartum * preexisting disease * hx PIH * alcohol use

RELATED HISTORY: Family History

*HA, thyroid dysfunction.

Chloasma

*aka: "Mask of Pregnancy" * > 16 weeks gestation blotchy, brownish, hyperpigmentation of face especially over malar prominences & forehead. * darkens with sun exposure & fades after delivery.

RELATED HISTORY: Personal/Social History

*employment: type of work, r/o head injury, helmet/safety head gear, exposure to chemicals/toxins * stress, tension, demands @ home/work/school. * potential risk of injury: sports, handrails available, seat belt use, car/booster seat, unsafe environment, illicit drugs. * nutrition: recent wt gain/loss, food intolerances, eating habits.

NECK is formed by

1) Cervical Vertebrae 2) Ligaments 3) Sternocleidomastoid Muscles: extends from upper sternum & medial 3rd of clavicle to mastoid process. 3) Trapezius Muscles: extends from scapula, lateral 3rd of clavicle & vertebrae to occipital prominence. ** Inferiorly: begins at the clavicles & sternum ** Superiorly: begins at the base of the skull ** Contains trachea, esophagus, internal/external jugular veins, common carotid, internal/external carotid arteries, & thyroid.

Facial muscles are INNERVATED by

1) Cranial Nerve (CN) V 2) Cranial Nerve (CN) VII

MAJOR facial landmarks

1) Palpebral fissures 2) Nasolabial folds

Ducts

1) Parotid (aka. Stensen Duct) opens into mouth next to maillary 2nd molar. 2) Submandibular (aka. Wharton Duct) opens into small papilla @ sides of frenulum.

SALIVA produced by PAIRED GLANDS

1) Parotid: located anterior to the ear & above mandible. 2) Submandibular: located medial to the mandible @ the angle of the jaw. 3) Sublingual: located anteriorly in the floor of the mouth. **Function of saliva: moisten mouth, inhibit dental caries, & start of CHO digestion.

Differential Diagnosis: HEADACHES

please review lavender chart on pages 197 - 198 for a complete review of specific types of headaches. * Assess: Onset, Duration, Location, Character, Severity, Visual Prodrome, Pattern, Episodes, change in LOC, Precipitating factors, efforts to treat. * medications to treat depend of root of headache. ABNORMALITIES OBJECTIVE DATA: normal physical exam with neurologic deficits: abnormal gait, papilledema, nystagmus