Ch 14 - Head, Face, Neck, and Regional Lymphatics

Major vessels/glands

Salivary glands •Parotid •Submandibular •Sublingual •Temporal artery

Headaches

•A leading reason for seeking care in outpatient clinics, urgent cares, and emergency departments •Subjective Questions: •Onset: When did this kind of headache start? •Gradual, over hours, or a day? •Suddenly over minutes, or less than 1 hour •Ever had this kind of headache before? •Location: Where do you feel it: frontal, temporal, behind your eyes, in sinus area, or in occipital area? •Is pain localized on one side or all over? •Character: throbbing, aching, mild, moderate, or severe? •Course and duration: When do headaches occur? Do they awaken you from sleep? •How long do they last? Hours or days? •Precipitating factors: What brings it on: activity, exercise, work environment, emotional upset, anxiety, alcohol? Note signs of depression •Associated factors: any relation to other symptoms •Nausea, vomiting, vision changes, pain with bright lights, neck pain or stiffness, fever, weakness, moodiness, stomach problems? •Do you have other illness or take any medications? •Pattern: Any family history of headache? •Frequency: Once a week? •For females: When do they occur in relation to your menstrual periods? •What seems to help: sleep, medications? •Coping strategies: How have headaches affected self-care, ability to work, home, and social ability?

Objective Data: Infants and Children, Neck

•An infant's neck looks short; it lengthens during the first 3 to 4 years •Assess muscle development with gentle passive ROM •Cradle infant's head with your hands and turn it side to side and test forward flexion, extension, and rotation •Note resistance to movement, especially flexion •During infancy, cervical lymph nodes are not palpable normally •Children's lymph nodes are palpable •Palpable nodes less than 3 mm are normal •Children have a higher incidence of infection, so you will expect a greater incidence of inflammatory adenopathy; no other mass should occur in neck

Developmental Competence: Infants and Children

•Bones of neonatal skull are separated by sutures and fontanels (soft spots), where the sutures intersect. Soft spots allow growth of brain during first year; gradually solidify •Triangle-shaped posterior fontanel closes by 1 to 2 months •Diamond-shaped anterior fontanel closes between 9 months and 2 years •In fetuses head growth is dominating, in infants trunk growth dominates •Head size is greater than chest circumference at birth and reaches 90% of final size at 6 years old •Facial bones grow at varying rates, in toddlers mandible/maxilla are small and nasal bridge is low •Lymph tissue is well developed at birth and reaching full maturation at 6 •In adolescent males, facial hair appears, thyroid cartilage enlarges, voice deepens

Objective Data: Infants and Children, Face

•Check facial features for symmetry, appearance, and swelling •Note symmetry of wrinkling when infant cries or smiles (e.g., both sides of lips rise and both sides of forehead wrinkle) •Normally, no swelling is evident •Parotid gland enlargement best seen when child looks up; swelling appears below angle of jaw

Additional Assessments and Considerations for Pregnant Women

•During second trimester, chloasma may show on face; a blotchy, hyperpigmented area over cheeks and forehead that fades after delivery •Thyroid gland may be palpable normally during pregnancy

Abnormal Findings: Fetal Alcohol Syndrome

•FAS •Cognitive, psychosocial, facial, and brain structure changes occur •Wide range of behavioral and neurological affects •May not present until childhood

Developmental Subjective Data

•For infants and children •Maternal alcohol or drug use? •Type of delivery? Vaginal or by cesarean section? Any difficulty? Use of forceps? •Growth pattern? Was it on schedule? •For aging adults •Dizziness? How does it affect your daily activities? •Neck pain? How does it affect your daily activities? Are you able to drive, perform at work, do housework, sleep, and look down when using stairs?

Additional Subjective Data: Headaches

•Head injury or blow to your head? •Dizziness? •Neck pain or limitation of neck motion? •Lumps or swelling? •History of head or neck surgery?

Thyroid

•Highly vascular endocrine gland that straddles the trachea •Synthesizes T3 and T4 hormones to stimulate cellular metabolism •2 lobes below thyroid cartilage •Thyroid cartilage has a small palpable notch in upper edge is often called the "Adam's apple" in males

Abnormal Findings: Head Size and Contour

•Hydrocephalus •Obstruction of drainage of cerebrospinal fluid results in excessive accumulation, increasing intracranial pressure, and enlargement of the head •Increasing pressure also produces dilated scalp veins, frontal bossing, and downcast or "setting sun" eyes (sclera visible above iris) •Cranial bones thin, sutures separate, and percussion yields a "cracked pot" sound

Sum it up!

•Inspect and palpate the skull •General size and contour •Note any deformities •Palpate temporal artery and temporomandibular join (TMJ) joint •Inspect and palpate the face •Observe facial expression •Cranial nerve VII: symmetry of movement •Observe for any abnormal movements •Inspect and palpate the neck and lymph nodes •Active ROM, potential enlargement and position of trachea, palpable lymph nodes •Auscultate thyroid (if enlarged) for bruit

Lymphatics

•Lymphatic system: an extensive vessel system, part of immune system, which detects and eliminates foreign substances from body •Lymph vessels allow flow of clear, watery fluid from tissue spaces into circulation •Lymph Nodes are small, oval clusters of lymphatic tissue that filter lymph and engulf pathogens •They prevent potentially harmful substances from entering the circulation •Head and neck have 60-70 lymph nodes •When lymph nodes are enlarged, check the area they drain, this is likely the source of the problem

Muscles

•Many appearances and moods are formed by facial muscles •Muscle are mediated by cranial nerve VII, the facial nerve •Symmetry should be present: eyebrows, eyes, ears, nose, mouth, nasolabial folds, palpebral fissures

Objective Data: Infants and Children, Skull

•Measure infant's head at each visit up to age 2 years and yearly up to age 6 years Variations of normal •Caput succedaneum •Cephalhematoma •Molding or positional molding Gently palpate skull and fontanels when infant is calm and somewhat upright •Skull should be smooth and fused except at fontanels •Fontanels should be firm, slightly concave, well defined, you may see/feel pulsations •Posterior fontanel may not be palpable at birth •Note head posture and control •Infants can turn head side to side at 2 weeks •Note tonic neck reflex in infants younger than 4 months •After 4 months, head control should be achieved. Infants can hold their head erect and steady

Inspection and Palpation of Lymph Nodes

•Normal nodes feel movable, discrete, soft, and nontender •If any nodes are palpable, note location, size, shape, delimitation (discrete or matted together), mobility, consistency, and tenderness •If nodes enlarged or tender, check area they drain for source of the problem; they often relate to inflammation or neoplasm •Follow up on or refer your findings; an enlarged lymph node, particularly when you cannot find the source of problem, deserves prompt attention

Inspection of the Face

•Note facial expression and appropriateness to behavior or reported mood •Facial structures always should be symmetric •Note any abnormal facial structures (coarse facial features, exophthalmos, changes in skin color or pigmentation), or abnormal swellings •Note any involuntary movements (tics) in facial muscles; normally none occur

Inspection and Palpation of the Skull

•Note general size and shape- normocephalic •Wide variation of "normal" •Assess shape: place fingers in person's hair and palpate scalp •Skull should feel symmetric and smooth Cranial bones that have normal protrusions •Forehead •Lateral edge of parietal bones •Occipital bone •Mastoid process behind each ear •Assess for tenderness •Palpate temporal artery above cheek bone (zygomatic) between eye and top of ear •Palpate temporomandibular joint with opening of mouth, note limitations, crepitation, or tenderness

Head Injury

•Onset? What happened? •Setting? Hazardous conditions? Wearing a helmet? •Feelings or symptoms before injury? •Loss of consciousness; before or after, for how long? •Medical history •Location of blow to the head •New symptoms and pattern of symptoms •Treatments given

Neck

•Passage way for many structures in close proximity (blood vessels, nerves, lymphatics, viscera of respiratory and digestive systems) •Internal and external carotid •Neck muscles allow head rotation and flexion, sternomastoid and trapezius are innervated by cranial nerve XI

Additional Assessments and Considerations for Children and Infants

•Percussion •With an infant, you may directly percuss with your plexor finger against head surface; this yields a resonant or "cracked pot" sound, which is normal before closure of fontanels •Auscultation •Bruits are common in skull of children under 4 or 5 years of age or children with anemia •Systolic or continuous; heard over temporal area

Location of Lymph Nodes

•Preauricular, in front of ear •Posterior auricular (mastoid), superficial to mastoid process •Occipital, at base of skull •Submental, midline, behind tip of mandible •Submandibular, halfway between angle and tip of mandible •Jugulodigastric, under angle of mandible •Superficial cervical, overlying sternomastoid muscle •Deep cervical, deep under sternomastoid muscle •Posterior cervical, in posterior triangle along edge of trapezius muscle •Supraclavicular, just above and behind clavicle, at sternomastoid muscle

Developmental Competence

•Pregnant female •Thyroid gland enlarges slightly during pregnancy as a result of hyperplasia of tissue and increased vascularity •Aging adult •Facial bones and orbits appear more prominent •Facial skin sags resulting from decreased elasticity, decreased subcutaneous fat, and decreased moisture in skin •Lower face may look smaller if teeth have been lost

Inspection and Palpation of the Neck

•Symmetry- head position should be midline, erect, and still with symmetrical muscles ROM and strength against resistance (cranial nerve XI) •Chin to chest •Left to right •Ear to shoulder •Extend backwards •Motion should be smooth and controlled •Look for swelling below angle of jaw; note thyroid gland enlargement though normally none is present •Note any obvious pulsations; carotid artery creates brisk localized pulsation just below angle of the jaw •Normally, there are no other pulsations while person is in sitting position

Additional Assessments and Considerations for the Aging Adult

•Temporal arteries may look twisted and prominent •In some aging adults, a mild rhythmic tremor of head may be normal •Senile tremors are benign and include head nodding and tongue protrusion •If some teeth have been lost, lower face looks unusually small, with mouth sunken in •Neck may show concave curve when head and jaw are extended forward to compensate for kyphosis of spine •Direct the aging person to perform ROM slowly to avoid dizziness •Prolapse of submandibular glands may be mistaken for a tumor; but drooping submandibular glands will feel soft and be present bilaterally

Bones

•The skull is rigid box that protects the brain and is supported by cervical vertebra •Cranial bones connected by sutures •Frontal •Parietal •Occipital •Temporal •Facial bones

Trachea and Thyroid Gland

•Trachea •Normally, trachea is midline; palpate for any tracheal shift •Space should be symmetric on both sides •Note any deviation from midline •Direction of deviation can be telling to pathologic cause •Thyroid Gland •Difficult to palpate in most adults; check for enlargement, consistency, symmetry, and presence of nodules •Posterior approach •Anterior approach •If enlarged, auscultate thyroid for presence of bruit, which occurs with accelerated or turbulent blood flow, indicating hyperplasia of thyroid (e.g., hyperthyroidism)

Palpating Lymph Nodes

•Using a gentle circular motion of finger pads, palpate lymph nodes •Beginning with preauricular lymph nodes in front of ear, palpate the 10 groups of lymph nodes in routine order •Many nodes are closely packed, so you must be systematic and thorough in your examination •Do not vary sequence or you may miss some small nodes