Chapter 15 - Assessing Head and Neck

Paget's Disease

acorn-shaped, enlarged skull bones seen in _________of the bone.

Orofacial movements

Unusual or asymmetric _______ may be from an organic disease or neurologic problem.

Southeast Asian

culture that prohibits touching the head or touching the feet before touching the head

temporal arteritis

inflammation of the temporal arteries that may lead to blindness. Temporal artery is hard, thick and tender with inflammation.

Chloasma

large brown patches form on the skin, mainly on the face

Cephalhematoma

a collection of blood under the scalp of a newborn; caused by pressure during birth

Caput succedaneum

a serosanguinous, subcutaneous, extraperiosteal fluid collection with poorly defined margins caused by the pressure of the presenting part of the scalp against the dilating cervix during delivery

Hyperthyroidism

a soft, blowing, swishing sound auscultated over the thyroid lobes is often heard in _______because of an increase in blood flow through the thyroid arteries

scleroderma

a tightened-hard face with thinning facial skin

microcephaly

abnormally small head

C7

vertebrae prominens is usually visible and palpable.

Traumatic Brain Injury

Results from - a bump, - jolt, - blow or penetrating injury to the head. Results from - falls, - MVA (Motor Vehicle accident), - assaults, - struck by or against solid surfaces

Parotid gland

Asymmetry in front of the earlobes occurs with __________ enlargement from an abscess or tumor.

Abnormal lymph node findings

Acute infection: discrete (separate) nodes, tender, enlarged, mobile side to side and up and down; larger than 1 cm.; often bilateral Chronic infection: nodes merge (confluent); larger than 1 cm. Metastatic cancers: larger than 1 cm.; enlarged, fixed in place, hard, firm, unilateral Virchow's Node - Supraclavicular (neoplasm of thorax & abdomen)

Vascular headaches

"Migranes" Can be caused by hormone fluctuations, fever or high blood pressure.

Muscle Contraction

"Tension" Caused by tightening of facial and neck muscles.

Torticollis

(Wry neck syndrome) A hematoma in 1 sternomastoid muscle, possibly injured in utero, results in head tilt to one side and limited ROM to the opposite side. This requires treatment or the muscle becomes permanently shortened.

Hyperthyroidism

*Goiter* is an increase in the size of the thyroid gland and occurs with hyperthyroidsm. *Graves' disease*, shown here is the most common cause of hyperthyroidism, manifested by goiter and exophthalmos (bulging eyeballs)

The Neck

- *Muscles * • Sternomastoid • Trapezius - * Vertebra prominens C7 * -* Blood Vessels* • Internal jugular veins • Carotid arteries -* Thyroid Gland* • Largest endocrine gland • Trachea surrounds the thyroid •*Lymph Nodes* - Filter lymph - Most are less than 1 cm. long - Either not palpable or may feel like small beads

The Face

- 14 facial bones - Temporal artery - Parotid glands - Facial expressions reflect mood - Structures are symmetric • Eyebrows, eyes, ears • Nose and mouth • Palpebral fissures • Nasolabial folds

Newborns & Infants

- Cranial bones are soft and separated by sutures which intersect at the fontanelles - Skull is asymmetric because of molding - Head size > chest at birth by ~ 2 cm

Aging Adult

- Facial bones appear more prominent; - facial skin sags RT decreased elasticity

Tension Headache

- Frontal or occipital - Bandlike/viselike *tightness* / *dull* - Anxiety or stress -- duration : days/months/years -- more common in women -- tx : local heat, massage, analgesics

Child/Adolescent

- In infancy the head grows proportionately; reaches 90% of full adult size by age 6 yrs - In adolescence the nose and thyroid cartilage enlarge - Lymph tissue is well developed at birth; tissue atrophies at puberty

Bell's Palsy

- Lower motor neuron - CN VII; Complete paralysis of ½ face - Usually unilateral - Cannot wrinkle forehead, raise eyebrow, close eye, whistle, or show teeth on affected side - Can start suddenly and peaks w/in 48 hrs. - Occurs often in pregnant women

Other causes of headaches

- Meningitis or encephalitis (nuchal rigidity & fever) - Hypertension - Fever - Medications/ substances • Oral contraceptives • Bronchodilators • Alcohol • Nitrates • Carbon monoxide

Tenderness

- Normal nodes are nontender - Tender, enlarged nodes suggest acute infection

Consistency

- Normally soft - Hard, firm, unilateral nodes are seen in metastatic cancers

Cluster headaches

- Pain around the eye, temple, forehead or cheek - *Always unilateral*, same side; excruciating - Worse with alcohol or daytime naps -- *Stabbing* - Eye redness and tearing, eyelid drooping, rhinorrhea and nasal congestion -- Commonly occurs in late evening -- movement/ walking makes it better -- more common in younger male

Client Education: Traumatic Brain Injury

- Seat belts, child safety seats - Avoid driving under the influence of alcohol - Helmets/head gear with risky activities, contact sports, skates, skateboards; baseball, horseback riding, skiing - Seniors: removing trip hazards; using nonslip mats, install grab bars

types of headaches

- Sinus - Cluster - Tension - migraine - Tumor related

Migraine Headaches

- Supraorbital, retro-orbital or fronto-temporal - Unilateral OR bilateral - *Throbbing*; severe - Worse w/stress, menses, eating cheese/chocolate - N/V & visual changes (sensitivity to light) - cause = Family HX -- more common in women -- duration : 3 days -- relief = rest

Mobility

- Typically they are mobile from side to side and up and down; - Abn. in metastatic disease they enlarge and become fixed in place

Brain Attack (CVA)

- Upper motor neuron - Neurological deficit - Paralysis of lower facial muscles; upper half not affected

Impending stroke

- a sudden, severe headache with no known -sudden trouble seeing in one or both eyes -trouble walking, dizziness, or loss of balance or coordination -sudden weakness or numbness in the face, arms, or legs, especially on one side

Symptoms of Head & Neck Cancer

- lump or sore that does not heal -sore throat that does not go away -trouble swallowing

• Delimitation

- position or boundary. Normally discrete - In chronic infection lymph nodes become confluent (merge) - In acute infection they remain discrete

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Medication That Cause Headaches

-Oral contraceptives -Blood-thinning medicines, such as warfarin, heparin, or aspirin -Caffeine (or caffeine withdrawal) -Heart or blood pressure medicines, such as nitroglycerin -Antihistamines and decongestants -Corticosteroids (prednisone) -Ergotamine (Cafergot) therapy -Hormone therapy (estrogen or progestin) -Medicines to prevent organ transplant rejection -Certain types of chemotherapy -Overuse of fat-soluble vitamins, such as Vitamin A and D -Radiation therapy

Causes of Headaches

-Vascular -Muscle Contraction -Traction -Inflammatory

Bell's Palsy

-begins suddenly and reaches pick within 48 hours -Symptoms: twiching, weakness, paralysis, drooping eyelid, drooling, dry mouth, facial distortion

Acromegaly

Acromegaly is characterized by enlargement of the facial features (nose, ears) and the hands and feet. It is caused by an increase in growth hormone after the skeleton and other organs finish growing; often due to benign pituitary tumor.

Lymph Nodes

Assess and note the following: -size and shape -delimitation (position or boundary) -mobility (move side to side) -consistency (soft) -tenderness and location

Drooping, weakness or paralysis

Caused by: -stroke -Bell's palsy

Cushing Syndrome

Cushing Syndrome results from excessive secretion of ACTH and chronic steroid use. The person develops - a rounded, "moonlike" face; - prominent jowls; - red cheeks; - hirsutism on the upper lip, lower cheeks, and chin; and acne type rash on the chest.

The Cranium

Houses and protects the brain & major sensory organs

Scleroderma

Literally "hard skin", a rare connective tissue disease characterized by *chronic hardening and shrinking* degenerative changes in skin, blood vessels, skeletal muscle. Changes can occur in skin, heart, esophagus, kidney, lung. You may see hard, shiny skin on the forehead and cheeks; thin, pursed lips, muscle atrophy on face & neck; absence of expression.

lymphadenopathy

Lymph node enlargement exceeds 1 cm, may be caused by acute or chronic infection, an autoimmune disorder,or metastatic disease

Trigeminal neuralgia (tic douloureux)

Manifested by sharp, shooting, piercing facial pains that last from seconds to minutes

arthritis or osteoporosis

May cause older adults to experience neck pain and a decreased range of motion.

Myxedema (Hypothyroidism)

Myxedema (Hypothyroidism) is a deficiency of thyroid hormone, when severe, causes a non-pitting edema or myxedema. Note puffy, edematous face, especially around eyes (periorbital edema), coarse facial features, dry skin, and dry, coarse hair and eyebrows.

Pregnant female

Thyroid gland enlarges slightly RT hyperplasia of the tissue & increased vascularity

Parkinson's Disease

a "mask-like" face

goiter

an enlarged thyroid gland; may appear as a large swelling at the base of the neck.

hyoid bone

arch-shaped bone that does not articulate directly with any other bone; located high in anterior neck

cachexia

emaciation or wasting; exhibits a "sunken" face with depressed eyes and hollow cheeks

generalized lymphadenopathy

enlargement of three or more groups. If persists longer than 3 mths may be a sign of HIV infection.

trapezius muscle

extends the head and move the shoulders

cricoid cartilage

first upper ring above the smooth tracheal rings

Neurologic disorders

may cause a horizontal jerking movements

Aortic insufficiency

may cause an involuntary nodding movement

Cushing's syndrome

moon-shaped face with reddened cheeks and increased facial hair

Subjective data

o Neck pain with muscular, cervical spine problems, stress, tension, meningeal inflammation--onset with stiffness and fever. o Headaches: COLDSPA questions re: description of symptoms, timing, precipitating factors, location, duration, severity, patterns, and associated factors o Difficulty moving head or neck, lumps or lesions, dizziness, lightheaded, spinning sensation, blurred vision, loss of consciousness; change in texture of skin, hair, nails, weakness, numbness o Head injury: with/without loss of consciousness; did it occur before or after the fall o Dizziness, lightheadedness, faintness (syncope), vertigo o Past Health history, family history and lifestyle factors

regional lymphadenopathy

one or two lymphatic groups enlarge

mandible

only movable bone in the face.

sterno-mastoid muscle

rotates and flexes the head

acromegaly

skull and facial bones that are larger and thicker and the hands and feet

Cranial bones joined together by immovable _________

sutures

Thyroid cartilage

under the hyoid bone, the area that widens at the top of the trachea; also known as the "Adam's apple"

Tumor-related

• *Aching*, steady; • location varies • neurologic & mental symptoms, N/V • Aggravated by coughing, sneezing, sudden movements • Commonly occurs in the morning

Subjective: Age-Specific

• *Newborn/Infant* - Did fontanelles close on schedule - Head growth - Head control • *Child/Adolescent* - Headaches/head injuries - Swollen neck glands - Neck stiffness • * Aging adults* - Difficulty with limited range of motion of neck - Neck pain with ADLs

Lymph Nodes

• *Preauricular*: in front of the ears • *Postauricular* behind the ears •* Occipital* at the posterior base of the skull • *Tonsillar* at the angle of the mandible; anterior edge of the sternomastoid muscle • *Submandibular* on the medial border of the mandible • *Submental* a few centimeters behind the tip of the mandible • *Superficial cervical* in the area superficial to the SM • *Posterior cervical* In the area posterior to the SM & and anterior to the trapezius in the posterior triangle • *Deep cervical* Deeply within and around the SM muscle • *Supraclavicular* deeply between the clavicles and the sternomastoid muscles - An enlarged, hard, non-tender node on the left may be metastasis

Risk Assessment: Traumatic Brain Injury

• Age - newborns - 4 yr - teens - over 65 • Transportation accidents • Violence • Falls • Excessive ETOH • Infants and elderly being cared for by caretivers

Lymphatics

• Be familiar with the direction of drainage patterns of lymph nodes. - When abnormal check the area they drain for the source of the problem. - Explore the area UPSTREAM of abnormal node

Palpate For Lymph Nodes

• Bend the head slightly toward the side being palpated to relax muscles in that area • Palpate with finger-pads in a slow walking, gentle, circular motion; compare lymph nodes bilaterally • Size and shape (normal lymph nodes are round and < 1 cm. are not palpable - Lymphadenopathy (nodes larger than 1 cm.) may be from acute or chronic infection, autoimmune disorders, or metastatic disease. Document location of node • *Regional* (1 or 2 groups) • *Generalized* (3 or more groups) that persist for more than 3 months, may be a sign of HIV infection.

The Childbearing Woman

• Chloasma may show on the face in 2nd trimester - Blotchy, hyperpigmented area over the cheeks & forehead - Fades after delivery - Thyroid gland may be normally palpable

Sinus headache

• Deep, *constant, throbbing* pain; in 1 specific area of face or head; • Occurs with a cold or acute sinusitis • Aggravated by bending forward, lying down, sudden movements, sudden temp change • *foul smelling breath*

Palpate For Lymph Nodes:

• Delimitation • Consistency • Mobility • Tenderness

Newborn/Infant: Face & Neck

• Face is proportionate & symmetric • Equal movements bilat • Parotid glands normal size • Neck is short with skin folds between the head & shoulder during infancy • Trachea is midline • Lymph nodes nonpalpable in infants • Clavicles symmetric & intact

8 Cranium bones

• Frontal, (B) • parietal, (A) X2 • occipital (C) • temporal, (D) X2 • ethmoid (G?) • sphenoid (E)

Inspect & Palpate the Neck

• Full ROM and strength (CN XI (Spinal accessory) - Abn. Stiff neck is a late symptom of meningitis; stiffness, rigidity and limited movement with arthritis • Trachea is midline - Abn. Pulled to affected side with atelectasis; unaffected side with pneumothorax • Palpate the thyroid gland (advanced procedure, not on exam) - Posterior v. anterior approach - Normally not palpable

Children/Adolescents: Inspect & Palpate Head, Face & Neck

• Head normocephalic & symmetric • Full ROM • Face proportionate & symmetric; movements equal bilat • Parotids normal size • Trachea is midline • Lymph nodes - Children: "shotty" (small, nontender, mobile) age 3-12 - Adolescents: usually nonpalpable

Subjective Data

• Headache • Neck pain • Medications • Limited ROM • Lumps or lesions • Cough or difficulty swallowing • Head injury, loss of consciousness • Blurred vision • Head or neck trauma • Dizziness, lightheadedness, spinning sensation • Change in energy level, skin, hair, nails; palpitations, • Weakness or numbness in face, arms, legs • Past history/Family History • Lifestyle/Health Practice

Hypothyroidism

• Increased sensitivity to cold • Constipation • Depression • Fatigue • Heavier menstrual periods • Pale, dry skin • Thin, brittle hair/nails • Weakness • Unintentional weight gain • If untreated may ---> - Decreased taste/smell - Hoarseness (a throaty harshness) - Puffy face, hands, feet - Slow speech - Thickening of skin - Thinning eyebrows

Inspection of the Face

• Inspect for symmetry, features, movement, expression and skin condition - Face is symmetric with a round, oval, elongated or square appearance without abnormal movements - Inspect eyebrows, palpebral fissures, nasolabial folds, sides of mouth • Abnormal: - Asymmetry with parotid enlargement, abscess or tumor - Drooping, weakness or paralysis with CVA or Bell's Palsy - Mask-like face with Parkinson's disease - Sunken face with depressed eyes & hollow cheeks (cachexia); - Pale, swollen face with nephrotic syndrome

Inspect & Palpate the Neck

• Inspect for symmetry, position, lumps or masses, & movement of neck structures - Neck is symmetric with head centered without bulging masses; thyroid cartilage moves symmetrically - Abn. Enlarged masses or nodules with enlarged thyroid gland or lymph nodes - Abn. Asymmetric movement of thyroid gland • Inspect cervical vertebrae: - C7 is visible & palpable

Newborns & Infants: Head

• Measure head @ each visit up to age 2 • Common variations - Molding with vaginal delivery - Caput succedaneum - Cephalhematoma • Inspect and palpate: normocephalic & symmetric • Palpate fontanelles and sutures - Should feel smooth and fused - Bulging w/ crying, vomiting or ↑ ICP - Depressed with dehydration or malnutrition - Anterior fontanel closes by 12-18 mos.; Posterior fontanel by age 2 mos. • Assess head control, head posture & ROM - Head control by 4 mos. of age; full ROM

Inspect & Palpate Head

• Size, shape & consistency - Normocephalic, hard, smooth, symmetric without lesions - Head is still, upright - No involuntary movements • Abn. - Microcephaly, - acromegaly, - jerking or nodding movements, - head tilt; - shortening of the sternomastoid muscle; - malignant lumps; - parotid enlargement

Hyperthyroidism

• Sudden weight loss, without changes in appetite • Increased appetite • Tachycardia & arrhythmia • Nervousness, anxiety & irritability • Tremor in hands fingers • Sweating • Changes in menstrual patterns • Increased sensitivity to heat • Changes in bowel patterns (more frequent) • Enlarged thyroid gland (goiter) • Fatigue, insomnia • Muscle weakness

Inspect & Palpate Head & Face

• Temporal Artery - Should be elastic & nontender - Abn. Tortuous, hard & tender with temporal arteritis • TMJ - Full ROM without crepitus, tenderness - Abn. Limited ROM, swelling, crepitus with TMJ syndrome

The Aging Adult

• There may be atrophy of face & neck muscles • Facial wrinkles are prominent because SQ fat decrease with age • Mouth may be drawn inward RT resorption of mandibular bone • Reduced ROM of head & neck is common • Neck is shorter due to vertebral degeneration • Cervical curvature may increase RT kyphosis • Temporal arteries may look twisted & prominent

14 facial bones

•Maxilla (2) •Zygomatic (cheek) (2) •Inferior conchae (2) •Nasal (2) •Lacrimal (2) •Palatine (2) •Vomer (1) •Mandible (jaw) (1)

Lymph Nodes

•Preauricular •Postauricular •Tonsillar •Occipital •Submandibular •Submental •Superficial cervical •Posterior cervical •Deep cervical •Supraclavicular