Chapter 15- Assessing Head and Neck

1/3 of the population

contain a third lobe of the thyroid gland

Cricoid cartilage

contains a small notch; smaller than the thyroid cartilage and is located inferior to it

First upper tracheal ring

cricoid cartilage

Tobacco/ Alcohol use

increases risk of head and neck cancer

submandibular glands

inferior to the mandible, underneath the base of the tongue

Thyroid cartilage

known as the Adam's apple, superior to and larger than the cricoid cartilage

Thyroid gland

largest endocrine gland; located on the trachea; consists of two lateral lobes that curve posteriorly on both sides of the trachea and esophagus and mostly covered by the sternocleidomastoid

External jugular veins

lies diagonally over the surface of sternomastoid muscles

Difficulty moving head or neck

limits mobility and affects activities of daily functioning

Radiation therapy

linked to thyroid cancer

Posterior triangle

located between the trapezius and sternomastoid

Internal jugular vein and carotid arteries

located bilaterally, parallel, and anterior to the sternomastoid muscles.

Parotid glands

located on each side of the face; anterior and inferior to the ears and behind the mandible

The neck is composed of..

muscles, ligaments, and cervical vertebrae

Sternomastoid and trapezius muscles..

paired muscles that allow movement and provide support to the head and neck (form the anterior and posterior triangles)

Appearance of lymph nodes

vary in size (2 to 100 individual nodes)

Traction and inflammatory headaches

warning signs of other illnesses such as stroke, sinus or gum infection, and meningitis

Cachexia

wasting of body due to severe chronic illness; sunken face with depressed eyes and hollow cheeks

Mononucleosis

swelling and pain of the lymph nodes due to infection by microorganisms

If hypothyroidism is not treated

symptoms of decreased taste and smell, hoarseness, puffy face, hands, feet, slow speech, thickening of skin, thinning of eyebrows

Lumps and lesions

that do not heal or disappear may indicate cancer

Contained within the neck are...

the hyoid bone, several major blood vessels, the larynx, trachea and thyroid gland (located in the anterior triangle of the neck)

All facial bones are immovable except

the mandible (free movement at the temporomandibular joint (TMJ)

Which cervical vertebrae are located in the posterior neck and support the cranium?

C1-C7

Vertebra prominens

C7, easily palpated when neck is flexed

Women and headaches

18% experience migraines due to hormones

What percentage of head and neck caners are linked to tobacco use?

85

Abnormal findings

Acromegaly- enlargement of facial features (nose, ears) and the hands and feet. Occurs in 6 of every 100,000 adults/ caused by: increased production of growth hormone after the skeleton and other organs finish growing. Due to non cancerous tumor of pituitary gland, also seen in Paget's disease. Cushing's syndrome-moonshaped face with reddened cheeks and increased facial hair Scleroderma- tightened hard fave with thinning facial skin Bell's Palsy- begins suddenly and reaches a peak within 48 hours. Symptoms include twitching, weakness, paralysis, drooping eyelid or corner of the mouth, drooling, dry eye, dry mouth, decreased ability to taste, eye tearing, facial distortion Exophthalmos- seen in hyperthyroidism (wide eyed)

Migraine headache

C- accompanied by nausea, vomiting, and sensitivity to noise or light O- precipitated by emotional disturbances, anxiety, or ingestion of alcohol, cheese, chocolate or other foods and substances which client is sensitive L- located round eyes, temples, cheeks, forehead; may affect only one side of face D- lasts up to 3 days S- throbbing, severe P- Rest may bring relief A- Occur more often in women

Tumor related headache

C- aching, steady, neurologic and mental symptoms as well as nausea and vomiting may develop O- may be aggravated by coughing, sneezing, or sudden movements of the head L- Varies with location of tumor D- commonly occurs in the morning and lasts for several hours S- variable in intensity P- usually subsides later in the day A-

Sinus headache

C- deep constant throbbing, pressure like pain ins specific area; face tender to touch O- after cold or acute sinusitis or acute febrile illness with purulent discharge from nose L- may occur in one area of face or alone eyebrow ridge and below the cheek bone D- last until associated condition improves S- moderately sever P- pain worse with sudden movements (bending, lying down, in the morning, sudden temp changes) A- nasal drainage, congestion, fever, foul smelling breath, tension headaches, migraines

Tension headache

C- dull, tight, diffuse O- may occur with stress, anxiety, or depression L- frontal, temporal, or occipital region D- lasts days, months, years S- aching P- symptomatic relief may be obtained by local heat, massage, analgesics, anti-depressants, muscle relaxants A- affects women more than men

Cluster headache

C- stabbing pain; accompanied by tearing/ eyelid drooping/ reddened eye/ runny nose O- sudden; precipitated by ingesting alcohol L- localized in eye and orbit/ radiating to facial and temporal regions D- typically occurs later in evening or night S- intense P- movement or walking back and forth may relieve discomfort A- Occur more in young males

Older adult (cervical)

Cervical curvature increase due to kyphosis Dowager's hump- more common in women: fat accumulation around the cervical vertebrae

Hypothyroidism

Cold, depressed, constipation, fatigue, heavier periods, pale, dry skin, thin, brittle nails or hair, weakness, weight gain

Order of cartilage

Hyoid ---> Thyroid ---> Cricoid

Fourteen bones of the face

Maxilla (2), Zygomatic (2), Inferior conchae (2), Nasal (2), Lacrimal (2), Palatine (2), Vomer (1), Mandible (1)

Auscultation of thyroid

Normal: no bruits Abnormal: soft, blowing, swishing sound auscultated over the thyroid lobes (heard in hyperthyroidism due to increase blood flow through the thyroid arteries.

Temporomandibular joint

Normal: no swelling, tenderness, or crepitation with movement; mouth opens and closes fully (3 to 6 cm between upper and lower teeth); lower jaw moves laterally 1-2 cm in each direction Abnormal: limited range of motion, swelling, tenderness, or crepitation (indicates TMJ syndrome)

Cervical vertebrae

Normal: C7 visible and palpable Abnormal: prominence or swelling other than C7

Temporal artery

Normal: elastic and not tender Abnormal: hard, thick, tender with inflammation Temporal arteritis (inflammation of the temporal artery that may lead to blindness)

Thyroid gland (palpate pt 2)

Normal: glandular thyroid tissue may be felt rising underneath fingers: lobes should be smooth, rubbery, and free of nodules Abnormal: coarse tissue or irregular consistency may indicate inflammatory process; nodules should be described in terms of location, size and consistency.

Palpate head

Normal: hard and smooth without lesions Abnormal: lesions or lumps on head may indicate recent trauma or sign of cancer

Thyroid gland (palpate)

Normal: landmarks are positioned midline Abnormal: landmarks deviate from midline or are obscured because of masses or abnormal growth NOTE: thyroid gland usually not palpable unless client has extremely thin, long neck. However, the isthmus may be palpated. If thyroid can be palpated the lobes are smooth, firm, and non tender, Right lobe 25% bigger than left Abnormal: Enlargement due to hyperthyroidism; Grave's disease or an endemic goiter: thyroid gland may be palpated. Enlarged, tender gland (thyroiditis) Multiple nodules of the thyroid may be seen in metabolic processes. However, rapid enlargement of a single nodule suggests malignancy.

Trachea (assessment)

Normal: midline Abnormal: pulled to affected side in case of large atelectasis, fibrosis or pleural adhesions pushed to unaffected side in case of tumor, enlarged thyroid lobe, pneumothorax, or aortic aneurysm

Inspect range of motion

Normal: smooth and controlled movement with 45 degree flexion 55 degree extension 40 degree lateral abduction and 70 degree rotation Abnormal: muscle spasms, inflammation; stiffness, rigidity and limited mobility of neck (cervical arthritis) Stiff neck is a late symptom of meningitis

Inspect the face

Normal: symmetric (round, oval, elongated, or square appearance) Abnormal: Asymmetry in front of the earlobes (parotid gland enlargement from abscess or tumor), unusual or asymmetric orofacial movements (organic disease or neurologic problem)

Neck

Normal: symmetric, head centered w/o bulging masses Abnormal: swelling, enlarged masses or nodules may indicate thyroid gland enlargement, inflammation of lymph nodes, tumor

Movement of neck structures

Normal: thyroid, cricoid cartilage move upward symmetrically as the client swallows Abnormal: Asymmetric movement or generalized enlargement of the thyroid gland

While palpating the lymph nodes

Note the following: Size and shape Delimitation Mobility Consistency Tenderness and location

Medications that cause headaches

Oral contraceptives, blood thinning medicines (warfarin, heparin, or aspirin), caffeine, heart and blood pressure meds (nitroglycerin), antihistamines and decongestants, corticosteriods, ergotamine therapy, hormone therapy (estrogen or progestin), medications to prevent organ transplant rejection, chemotherapy, overuse of fat soluble vitamines (A&D), Radiation therapy

Name of head and neck lymph nodes

Preauricular (in front of ear), Posterior auricular (behind ear), Tonsillar (inferior to posterior auricular) Occipital (back of the neck) Submandibular (similar to the gland) Submental (inferior to mandible near the chin), Superficial cervical (on top of the sternomastoid), Posterior Cervical (in posterior triangle), Deep cervical (underneath sternomastoid), Supraclavicular (superior to clavicule)

Lymph nodes (palpate)

Preauricular nodes- Normal: no swelling or enlargement or tender Abnormal: enlarged nodes Tonsillar- Normal: no swelling or hardness or tender Abnormal: swelling, tenderness, hardness, immobility Submandibular- Normal: no enlargement or tenderness Abnormal: enlargement and tenderness Submental nodes/ Superficial cervical/ Posterior cervical/ Deep cervical Normal: no enlargement or tenderness Abnormal: enlargement/ tenderness Supraclavicular Normal: no enlargement or tenderness Abnormal: enlarged, hard, nontender, particularly on the left side; indicates metastasis from a malignancy in the abdomen or thorax

Thyroid gland connected by

an isthmus that overlies that second and third tracheal rings below the cricoid cartilage

Hyoid bone

attatched to the tongue, lies above the thyroid cartilage and under the mandible

When assessing the neck...

avoid bilateral compression on the carotid arteries- results in reducing the blood supply to the brains

Poor posture

can cause head and neck discomfort and exacerbate the problem

Muscle contraction headaches

caused by tightening of facial and neck muscles

Lymph

clear substance composed mostly of excess tissue fluid

Indication of cancer

enlarged lymph nodes, but not painful

Goiter

enlarged thyroid gland, appears as a large swelling at the base of the neck; goiters can result in tight feeling in the through, cough, hoarseness, difficulty swallowing, horse voice

Cultures

ex. Southeast Asian prohibits teaching the head or touching the feet before the head

Vascular headaches

ex. migraine, can be caused by fever or high BP

Trapezius muscle

extends the head and moves the shoulders

Older adult (face)

facial wrinkles due to fat decreasing with age, lower face may shrink and mouth drawn inward (resorption of mandibular bones (also an age related process))

Lymph nodes

filter lymph after the lymphatic vessels collect it but before it returns to the vascular system; produces lymphocytes and antibodies as a defense against invasion by foreign substances.

Head and neck assessment

focuses on the cranium, face, thyroid gland, and lymph nodes contained with the head and neck

Eight bones of the cranium

frontal, occipital, parietal (2), temporal (2), ethmoid and sphenoid

Migraine headaches

have a familial association

Cranium

houses and protects brain and sensory organs

Increased radiation doses increases the risk of

hypothyroidism

Nasolabial folds and palpebral fissures

ideal places to check facial features for symmetry

Cranial bones are joined together by...

immovable sutures; sagittal, coronal, squamosal, and lambdoid

Head and neck cancers symptoms

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

Temporal artery

major artery located between the eye and the top of the ear

Trigeminal neuralgia (tic douloureux)

manifested by sharp, shooting, piercing facial pains that last from seconds to minutes. Pain occurs over the divisions of the fifth trigeminal cranial nerve (opthalmic, maxillary, and mandibular areas)

Parkinsion's disease

mask like face

Neck pain

may accompany muscular problems or cervical spinal cord problems

Sudden trouble seeing or walking (dizziness, lightheadedness, loss of coordination) indicates

may be a sign of impending stroke

Nephrotic syndrome

may cause a pale, swollen face

Previous head and neck trauma

may cause chronic pain and limitation of movement, may also affect functioning

Radiation to the neck

may cause esophageal strictures and leading to difficulty swallowing

Stress and tension

may increase neck pain

Sudden weakness or numbness in the face, arms, legs especially one side of the body..

may indicate impending stroke

Drooping, weakness, paralysis on one side of face

may result from a stroke (cerebrovascular accident CVA) also; may result from Bell's palsy (neurologic condition)

Normal size of lymph nodes

most are less than 1 cm long (buried deep in connective tissue) either not palpable or feel like very small beads

Headaches

most commonly related to vascular (migraine), muscle contraction (tension), traction or inflammatory causes

Involuntary movement inspection

normal: head should be still and upright abnormal: horizontal jerking movement (neurological disorder), involuntary nodding (aortic insufficiency) head tilted to one side (unilateral vision, hearing deficiency or shortening of the sternomastoid muscle)

Head inspection

normal: head size and shape vary; usually symmetric, round, erect, and in midline and related to body size, no lesions visible abnormal: small head (microcephaly), acromegaly (skull and facial bones longer and thicker), acorn-shaped, enlarged skull bones (Paget's disease of the bone)

Filtering

removes bacteria and tumor cells from lymph

Genetic predisposition

risk factor for head and neck cancers

Sternomastoid muscle

rotates and flexes head

Sudden, sever headache

sign of impending stroke

Older adult (range of motion)

somewhat decreased flexion, extension, lateral bending, and rotation of the neck usually due to arthritis

Eleventh cranial nerve

spinal accessory; responsible for muscle movement that permits shrugging of the shoulders by the trapezius muscle and turning the head against resistance by the sternomastoid muscles

Assessment equipment

stethoscope and a small cup of water

Meningeal inflammation

sudden neck and head pain seen with elevated temperature and neck stiffness

Client dizziness, spinning, lightheadedness, loss of consciousness

these symptoms may indicated problems with the heart and neck vessels, peripheral vascular system or neurological system

Overlap of body systems in the head and neck

thorough nursing history need to detect underlying systemic problems

Thyroid gland produces

thyroid hormones that increase metabolic rate

Anterior triangle

under mandible, anterior to sternomastoid

Hyperthyroidism

weight loss (w.o changes in appetite and diet), increased appetite, tachycardia, arrhythmia (irregular heart beat) or palpitations, nervousness, anxiety, irritability, tremor in hands and fingers, sweating, changes in period patterns, increased sensitivity to heat, change in bowel patterns (frequent), goiter, fatigue, insomnia, muscle weakness

Trachea

where air enters the lung, composed of C-shaped hyaline cartilage rings