HA- Chapter 10: Head and Neck

Midline Structures and Thyroid Gland

(1) the mobile hyoid bone just below the mandible, (2) the thyroid cartilage, readily identified by the notch on its superior edge, (3) the cricoid cartilage, (4) the tracheal rings, and (5) the thyroid gland.

tension headaches

-Episodic -Tend to peak after several hours -Often arise in temporal area -Consider medication overuse Often self treated

migraines

-Episodic -Tend to peak over several hours -Unilateral -Prodromal onset and/or aura -Nausea and vomiting -Positive family history most frequent headache seen in office visits most debilitating last up to 3 days Approximately 60% to 70% of patients with migraine have a prodrome prior to onset; 20% experience an aura, including photophobia, scintillating scotomata, or reversible visual and sensory symptoms. Family history may be positive in patients with migraines.

Lifespan Considerations: The Aging Adult

-Facial bones and orbits appear more prominent -Facial skin sags -Decreased elasticity -Decreased subcutaneous fat -Decreased moisture in the skin -Lower face may look smaller -Cervical curvature may increase due to kyphosis -Fat may accumulate around cervical vertebrae - "dowager's hump" -Mildly decreased ROM due to arthritis

Family History

-History of head or neck cancer in family? -History of migraine headaches in family?

Lifestyle and Health Practices

-History of smoking, oral tobacco, alcohol use Both increase the risk of head and neck cancers -Quantify use -What type alcohol? How many drinks per day, per week? -Packs/day x number of years for cigarette use -Number of cans/day or week for oral tobacco -Vaping - newest concern, increasing use among teenagers and young adults -Types of recreational activity -Helmet use - bike, motorcycle, 4-wheeler, horse, occupational hazards: ex work in a plant, construction zone working

Objective data Neck

-Inspect for position, symmetry, lumps, nodules, masses, obvious tracheal deviation or goiter (enlarged thyroid) -Neck should be symmetric with head centered and without masses -Neck muscles (accessory muscles of breathing) should be symmetrical -Presence of swelling, masses or nodules could indicate enlarged thyroid gland, enlargement of lymph nodes or a tumor

Exam Head and Neck

-Inspect/palpate head, scalp, hair -Inspect face for symmetry, note skin characteristics, facial expression, any involuntary movements -Abnormal facial features may be noted with acromegaly, Cushing syndrome, Bell's palsy, CVA, hyper/hypothyroidism, scleroderma -Palpate temporal artery -Should feel elastic and should be non-tender -Temporal arteritis - the temporal artery is inflamed and is hard thickened, and tender on exam -Palpate temporomandibular joint (TMJ) -Movement should be smooth without pain -Limited ROM, swelling, tenderness or crepitation may indicate TMJ dysfunction -If signs noted on exam, any patient history of headaches?

TBI Risk Reduction: Older Adults

-Making living areas safer for older adults, by: -Removing tripping hazards such as throw rugs and clutter in walkways -Using nonslip mats in the bathtub and on shower floors -Installing grab bars next to the toilet and in the tub or shower- Installing handrails on both sides of stairways -Improving lighting throughout the home

Primary Headache

-No identifiable underlying cause -Steady, pressing or tightening, mild to moderate intensity

Objective Data: Trachea

-Palpate the trachea -Place thumbs in the sternal notch, slip fingers off to each side and note any deviation of trachea -Trachea may be deviated with tumor, enlarged thyroid lobe, pneumothorax, aortic aneurysm -Palpate the thyroid gland for enlargement or nodules -Locate key landmarks - hyoid bone, thyroid cartilage (Adam's apple), cricoid cartilage -Thyroid is located below cricoid cartilage; usually non-palpable, may feel thyroid isthmus; if palpable, should be smooth, firm, non-tender -Use posterior approach - Offer water and ask patient to hold in their mouth. Ask patient to turn head to right side, look downward, displace trachea to right and palpate thyroid on right with the right hand while patient swallows. Do other side -If thyroid enlarged, auscultate with bell of stethoscope for a bruit

sinus headache

-Pressure-like, throbbing pain in one specific area of face -Above eyebrows, under eyes -May be tender to touch

Past Health History

-Previous head or neck problems? -Trauma, injury, falls -How treated? -What were the results? -Head or neck surgery? -History of radiation to neck? -Head injury? -Headache with certain medications?

New, persisting, progressively severe headache

-Raise concerns of tumor, abscess, or mass - sudden and severe, consider subarachnoid hemorrhage related to head injury, meningitis, or stroke -Nausea and vomiting

Preparing for Head Exam

-Remove any wig, hat, hair barrettes, etc. and head and neck scarves Equipment: -Small cup of water -Stethoscope -Tangential light Order -Cranial Nerves I-XII -Neurologic exam -Head/face -Eyes -Ears -Nose, mouth, throat, -Neck

Common/Concerning for Neck

-Swollen lymph nodes or neck lumps -Enlarged thyroid gland -Hoarseness CHECK TEXTURE OF SKIN/HAIR dizziness, light-headed, spinning, weakness/numbing in the face, numbness in the body, change in palpitations, energy levels

opening questions assessing headaches

"Have you experienced unusually severe headaches?" "Have you experienced unusually frequent headaches?" Onset: When did you first notice the headache? Location: Where do you feel the headache? Can you point to the area(s)? Duration: How long has this been going on? Characteristic symptoms: Describe what it feels like (throbbing, hammering, squeezing). Associated manifestations: Do you notice any other symptoms when this occurs? Blurred vision? Nausea? Vomiting? Dizziness? What happened prior to the headache? Did anything precipitate the pain? Is there a prodrome of unusual feelings such as euphoria, craving for food, fatigue, or dizziness? Is there an aura with neurologic symptoms, such as change in vision or numbness or weakness in an arm or leg? What brings the headache on (specific foods or drinks, exercise, stress, work, environment, menstruation)? Is there a history of overuse of analgesics (e.g., NSAIDS), ergotamine, or triptans? Do you have a family or personal history of headaches? Relieving Factors: What have you tried to make the headache go away? Treatment: Has anyone treated you for headaches in the past? Ask whether coughing, sneezing, or changing the position of the head has any effect (better, worse, or none) on the headache. Such maneuvers may increase pain from a brain tumor and acute sinusitis.

cluster migraibes

-unilateral pain seen -can be retroorbital

Assessing Hair

Abnormalities covered by the hair are easily missed, so ask if the patient has noticed anything different or any changes with the scalp or hair. Ask the patient to remove any hair pieces, hair adornments, scarves, or rubber bands Note its quantity, distribution, texture, and pattern of loss, if any. You may see loose flakes of dandruff. Fine hair accompanies hyperthyroidism; coarse hair is found with hypothyroidism. Tiny white ovoid granules that adhere to hairs may be nits (eggs of lice).

Common concerning symptoms of head

Headache Head injury Head or neck surgery Traumatic brain injury FIRST: ASK ABOUT LOSS OF CONSCIOUSNESS

headache

Headache is one of the most common complaints in clinical practice, with a prevalence of 47% of the adult population experiencing symptoms in the past year. -global issue -tension headaches -migraine -primary/secondary Every headache warrants careful evaluation for life-threatening causes such as meningitis, subdural or intracranial hemorrhage, or tumor. get full description of headache The most important attributes are the headaches' severity and chronologic patterns. If a headache is severe and of sudden onset, consider subarachnoid hemorrhage, meningitis, or stroke.

Inspecting thyroid gland

Inspect the neck for the thyroid gland. Tip the patient's head back a bit. Using tangential lighting directed downward from the tip of the patient's chin, inspect the region below the cricoid cartilage for the gland. The lower shadowed border of each thyroid gland shown here is outlined by arrows. Ask the patient to sip some water and to extend the neck again and swallow. Watch for upward movement of the thyroid gland, noting its contour and symmetry. The thyroid cartilage, the cricoid cartilage, and the thyroid gland all rise with swallowing and then fall to their resting positions. With swallowing, the lower border of this large gland rises and looks less symmetric. Palpating the thyroid gland may seem difficult at first. Use the cues from visual inspection. Find your landmarks—the notched thyroid cartilage and the cricoid cartilage below it. Locate the thyroid isthmus, usually overlying the second, third, and fourth tracheal rings.

Assessing the neck

Inspect the neck, noting its symmetry and any masses or scars. Look for enlargement of the parotid or submandibular glands, and note any visible lymph nodes. A scar of past thyroid surgery is often a clue to under-reported thyroid disease.

Inspecting the trachea

Inspect the trachea for any deviation from its usual midline position. Then feel for any deviation. Place your finger along one side of the trachea and note the space between it and the sternocleidomastoid. Compare it with the other side. The spaces should be symmetric. Masses in the neck may push the trachea to one side. Tracheal deviation may also signify important problems in the thorax, such as a mediastinal mass, atelectasis, or a large pneumothorax

Assessing the face

Note the patient's facial expression and contours. Observe for asymmetry, involuntary movements, edema, and masses.

Assessing the Skull

Observe the general size and contour of the skull. Note any deformities, depressions, lumps, or tenderness. Learn to recognize the irregularities in a normal skull, such as those near the suture lines between the parietal and occipital bones.

Assessing the skin

Observe the skin, noting its color, pigmentation, texture, thickness, hair distribution, and any lesions. Acne is found in many adolescents. Hirsutism (excessive facial hair) occurs in some women with polycystic ovary syndrome.

Objective data: lymph nodes

Palpate the lymph nodes of the head and neck -Establish a sequence or pattern that is followed for assessment -Note location, size, shape, consistency, mobility, tenderness, delimitation -Normal node: < 1cm, mobile, soft; Abnormal node: > 2cm, hard, fixed -Enlargement > 1cm is termed lymphadenopathy -Should not be able to palpate all lymph nodes in head and neck -Don't state, "they are all palpable and < 1cm" -If lymph nodes are palpable, note location, characteristics, and consider drainage patterns -Enlargement and tenderness are abnormal -Enlargement of supraclavicular nodes could indicate a malignancy in abdomen, thorax, or breast

Lymph Nodes assessment

Palpate the lymph nodes. Using the pads of your index and middle fingers, move the skin over the underlying tissues in each area in a circular motion. The patient should be relaxed, with neck flexed slightly forward and, if needed, slightly toward the side being examined. You can usually examine both sides at once. For the submental node, however, it is helpful to feel with one hand behind the mandible. You should be able to roll a node in two directions: up and down, and side to side. Neither a muscle nor an artery will pass this test. Feel in sequence for the following nodes: 1. Preauricular—in front of the ear 2. Posterior auricular—superficial to the mastoid process 3. Occipital—at the base of the skull posteriorly 4. Tonsillar—at the angle of the mandible 5. Submandibular—midway between the angle and the tip of the mandible. These nodes are usually smaller and smoother than the lobulated submandibular gland against which they lie. 6. Submental—in the midline a few centimeters behind the tip of the mandible 7. Superficial cervical—superficial to the sternocleidomastoid 8. Posterior cervical—along the anterior edge of the trapezius 9. Deep cervical chain—deep to the sternocleidomastoid and often inaccessible to examination. Hook your thumb and fingers around either side of the sternocleidomastoid muscle to find them. 10. Supraclavicular—deep in the angle formed by the clavicle and the sternocleidomastoid Most lymph nodes cannot be palpated. When a node is detected on palpation, note its size, shape, delimitation (discrete or matted together), mobility, consistency, and any tenderness. Small, mobile, discrete, nontender nodes, sometimes termed "shotty," can frequently be found, especially in children.

Assessing the Scalp

Part the hair in several places and look for scaliness, lumps, nevi, or other lesions. Redness and scaling may indicate seborrheic dermatitis, psoriasis; soft lumps of pilar cysts; or pigmented nevi.

Secondary headaches

Secondary headaches arise from other conditions—some of these may endanger the patient's life. Look for "red flags" that raise suspicion of worrisome secondary causes: recent onset (less than 6 months); onset after 50 years of age; acute onset like a "thunderclap," or "the worst headache of my life" ; markedly elevated blood pressure; presence of rash or signs of infection; presence of cancer, HIV, or pregnancy; vomiting; recent head trauma; or persisting neurologic deficits.

Objective data for head physical exam

Steps include: -Inspect/palpate head for size, shape, symmetry -Inspect scalp for lesions, nevi -Inspect hair for color, distribution, texture -Inspect face for symmetry -Palpate temporal arteries -Palpate temporomandibular joint for swelling, tenderness, or crepitation -Inspect neck for symmetry, masses, obvious tracheal deviation, goiter (enlarged thyroid) -Palpate for any enlarged or tender lymph nodes -Palpate trachea for deviation -Palpate thyroid for enlargement or nodules -Auscultate for bruits over thyroid if enlarged

Common or Concerning Symptoms of the Neck

Swollen lymph nodes or neck lumps Enlarged thyroid gland Hoarseness OLDCARTS Enlarged tender lymph nodes commonly accompany pharyngitis. Assess thyroid function and ask about any evidence of an enlarged thyroid gland or goiter. To evaluate thyroid function, ask about temperature intolerance and sweating- Intolerance to cold, preference for warm clothing and many blankets, and decreased sweating suggest hypothyroidism; the opposite symptoms, palpitations, and involuntary weight loss suggest hyperthyroidism

Hypothyroidism

Symptoms: Fatigue, lethargy Modest weight gain with anorexia Dry, coarse skin and cold intolerance Swelling of face, hands, and legs Constipation Weakness, muscle cramps, arthralgias, paresthesias, impaired memory and hearing Signs Dry, coarse, cool skin, sometimes yellowish from carotene, with nonpitting edema and loss of hair Periorbital puffiness Decreased systolic and increased diastolic blood pressures Bradycardia and, in late stages, hypothermia Intensity of heart sounds sometimes decreased Impaired memory, mixed hearing loss, somnolence, peripheral neuropathy, carpal tunnel syndrome

Hyperthyroidism

Symptoms: -Nervousness -Weight loss despite increased appetite -Excessive sweating and heat intolerance -Palpitations -Frequent bowel movements -Muscular weakness of the proximal type and tremor Signs: Warm, smooth, moist skin With Graves disease, eye signs such as stare, lid lag, and exophthalmos Increased systolic and decreased diastolic blood pressures Tachycardia or atrial fibrillation Hyperdynamic cardiac pulsations with an accentuated S1 Tremor and proximal muscle weakness

TBI Prevention

The Centers for Disease Control and Prevention note that 40% of all TBIs are caused by falls, which is the overall leading cause of TBIs in the United States. The leading causes of TBI are falls, being hit or struck by an object, and motor vehicle accidents. Teaching patients about prevention of head injuries is paramount. Adolescents are more likely to sustain a TBI from a fall, blunt trauma (e.g., sports-related injury) or a motor vehicle accident. There has been increased research on the prevention and care of TBIs.

Lymphatic System

The lymphatic system is a part of the immune system. Its function is to detect and eliminate foreign substances. One part of the lymph system is in the head and neck. The nurse needs to be aware of the drainage pattern.

Goiter

With goiter, thyroid function may be increased, decreased, or normal.

TBI

a blow to the head or a piercing head injury that interferes with the function of the brain. Not all injuries to the head result in a TBI, and those that do occur span from mild to severe. Mild cases involve a slight change in mental status or consciousness and severe is an extended change postinjury. The severe cases account for approximately 30% of all deaths related to injuries. -Accidents involving automobiles, motorcycles, bicycles, and pedestrians -Violence, such as firearm assaults and child abuse or self-inflicted wounds -Falling -Excessive alcohol ingestion -Infants and elderly being cared for by caregivers -Not all injuries to head result in brain injury. -May be mild to severe -May be time lapse between injury and manifestation of symptoms

lymph nodes: posterior cervical

along the anterior edge of the trapezius

Macrocephaly

an anomaly characterized by a large head in proportion to the body and an underdeveloped brain. The circumference of the head is more than two standard deviations above average for the person's age and sex.

Lymph nodes: tonsillar

angle of mandible A "tonsillar node" that pulsates is really the carotid artery. A small, hard, tender "tonsillar node" high and deep between the mandible and the sternocleidomastoid is probably a styloid process.

microencephaly

anomaly characterized by a small head in proportion to the body and an underdeveloped brain. The circumference of the head is more than two standard deviations below average for the person's age and sex.

Lymph nodes: occipital

at the base of the skull posteriorly

Lymph nodes: supraclavicular

deep in the angle formed by the clavicle and the sternocleidomastoid Enlargement of a supraclavicular node, especially on the left, suggests possible metastasis from a thoracic or an abdominal malignancy.

lymph nodes: deep cervical chain

deep to the sternocleidomastoid and often inaccessible to examination. Hook your thumb and fingers around either side of the sternocleidomastoid muscle to find them.

Anatomy and Physiology of the Neck

divide each side of the neck into two triangles bounded by the sternocleidomastoid muscle. Visualize the borders of the two triangles as follows: For the anterior triangle: the mandible above, the sternocleidomastoid laterally, and the midline of the neck medially For the posterior triangle: the sternocleidomastoid muscle, the trapezius, and the clavicle. Note that a portion of the omohyoid muscle crosses the lower portion of this triangle and can be mistaken for a lymph node or mass.

Regions of Head

frontal, pariental, ocipital, temporal

Lymph nodes: preauricular

in front of the ear d palpate the preauricular nodes with a gentle rotary motion

Lymph nodes: submental

in the midline a few centimeters behind the tip of the mandible submental is palpated with one hand.

lymph nodes: submandibular

midway between the angle and the tip of the mandible. These nodes are usually smaller and smoother than the lobulated submandibular gland against which they lie.

Lymph nodes: posterior auricular

superficial to the mastoid process

Lymph nodes: superficial cervical

superficial to the sternocleidomastoid

Headache warning signs

•Progressively frequent or severe over 3 months •Sudden onset like "thunderclap" •New onset after age 50 years •Precipitated by Valsalva •Associated symptoms of fever, night sweats or weight loss •Presence of cancer, HIV infection, or pregnancy •Recent head trauma •Change in pattern from past headaches •Lack of a similar headache in the past •Associated papilledema, neck stiffness or focal neurologic deficits: looking for MENINGITIS