Ch. 13 Head, Face, Neck Including Regional Lymphatics

Cachectic Appearance

accompanies chronic wasting diseases such as cancer, dehydration, and starvation. Features include sunken eyes; hollow cheeks; and exhausted, defeated expression

Inspect the face-Facial structures

inspect the face, noting the facial expression and its appropriateness to behavior or reported mood. Anxiety is common in the hospitalized or ill person. Facial structures should always be symmetric-eyebrows, palpebral fissures, nasolabial folds, and sides of the mouth. Abnormal findings: tense, rigid muscles may indicate anxiety or pain; a flat affect may indicate depression. Marked asymmetry with central brain lesion (e.g. stroke) or with peripheral cranial nerve VII damage (Bell's palsy). Edema in the face occurs first around the eyes (periorbital) and the cheeks where the subcutaneous tissue is relatively loose. Note grinding of jaws, tics, fasciculations, or excessive blinking.

Cephalhematoma

is a subperiosteal hemorrhage, which is also a result of birth trauma. It is soft, fluctuant, and well defined over one cranial bone because the periosteum holds the bleeding in place. It appears several hours after birth and gradually increases in size. Rarely, a large hematoma may persist to 3 months . Abnormal findings: An infant with cephalhematoma is at greater risk for jaundice as the red blood cells within the hematoma are broken down and reabsorbed.

Caput succedaneum

is edematous swelling and ecchymosis of the presenting part of the head caused by birth trauma. It feels soft, and it may extend across suture lines. It gradually resolves during the first few days of life and needs no treatment.

Lymphoid tissue in children

is well developed at birth and grows to adult size when the child is 6 years old. The child's lymphatic tissue continues to grow rapidly until age 10 or 11 years actually exceeding its adult size before puberty, then the tissue slowly atrophies.

Supraclavicular lymph node

just above and behind the clavicle, at the sternomastoid muscle

Scleroderma

literally "hard skin" this rare connective tissue disease is characterized by chronic hardening and shrinking degenerative changes in the skin, blood vessels, synovium, and skeletal muscles. Changes can occur in the skin, heart, esophagus, kidney, and lung. Characteristic facies: hard shiny skin on forehead and cheeks; thin, pursed lips with radial furrowing; absent skinfolds; muscle atrophy on face and neck; absence of expression.

Inspect the neck

look for symmetry-head position is centered in the midline, and the accessory neck muscles should be symmetric. The head should be held erect and still. Abnormal findings: head tilt occurs with muscle spasm. Rigid head and neck occur with arthritis. Thyroid enlargement may be a unilateral lump, or it may be diffuse and look like a doughnut lying across the lower neck.

Thyroid-Multiple Nodules

multiple nodules usually indicate inflammation or a multi-nodular goiter rather than a neoplasm.

Goiter

a chronic enlargement of the thyroid gland that occurs in some regions of the world where the soil is low in iodine. Not due to neoplasm.

Parkinson Syndrome

a deficiency of the neurotransmitter dopamine and degeneration of the basal ganglia in the brain. The immobility of features produces a face that is flat and expressionless, "mask like," with elevated eyebrows, staring gaze, oily skin, and drooling.

Myxedema (Hypothyroidism)

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.

Torticollis (Wryneck)

a hematoma in one sternomastoid muscle, probably injured by intrauterine malposition, results in head tilt to one side and limited neck ROM to the opposite side. You will feel a firm, discrete, non-tender mass in mid-muscle on the involved side. This requires treatment, or the muscle becomes fibrotic and permanently shortened with permanent limitation of ROM, asymmetry of head and face and visual problems forma non-horizontal position of the eyes.

Bell's Palsy

a lower motor neuron lesion (peripheral), producing cranial nerve VII paralysis, which is almost always unilateral. Complete paralysis of one side

Skull

a rigid bony box that protects the brain and special sense organs, and it includes the bones of the cranium and face.

Palpate the lymph nodes

using a gentle circular motion of your fingerpads, use gentle pressure; it is most efficient to palpate with both hands comparing the two sides symmetrically. If any nodes are palpable, note their location, size, shape, delimitation, mobility, consistency, and tenderness. Cervical nodes are often palpable in healthy persons, although this palpability decreases with age. Normal nodes feel movable, discrete, soft, and nontender. Abnormal findings: Lymphadenopathy- enlaragement of the lymph nodes(>1cm) from infection, allergy, or neoplasm.

The aging adult-old people

temporal arteries may look twisted and prominent. In some aging adults, a mild rhythmic tremor of the head may be normal. If some teeth have been lost, the lower face looks unusually small, with the mouth sunken in. The neck may show an increased anterior cervical (concave or inward) curve when the head and jaw are extended forward to compensate for kyphosis of the spine.

Where is the anterior triangle located?

the anterior triangle lies in front, between the sternomastoid and the midline of the body, with its base up along the lower border of the mandible and its apex down at the suprasternal notch.

The Aging Adult

the facial bones and orbits appear more prominent, and the facial skin sags as a result of decreased elasticity, decreased subcutaneous fat, and decreased moisture in the skin. The lower face may look smaller if teeth have been lost.

What are the major neck muscles?

the major neck muscles are the sternomastoid and the trapezius; they are innervated by cranial nerve IX, the spinal accessory.

Toddler facial bones

the mandible and maxilla are small and the nasal bridge is low, so that the whole face seems small compared with the skull

Infant Head

the newborn's head measures about 32 to 38 cm (avg around 34 cm) and is 2 cm larger than chest circumference. At age 2 years, both measurements are the same. During childhood, the chest circumference grows to exceed head circumference by 5-7 cm. Abnormal findings: Microcephalic-head size below norms for age. Macrocephalic-an enlarged head or rapidly increasing in size (e.g. hydrocephalus [increased cerebrospinal fluid]).

Name the two salivary glands that are accessible to examination on the face.

the parotid and submandibular glands.

Where are the parotid glands located?

the parotid glands are in the cheeks over the mandible, anterior to and below the ear. They are the largest of the salivary glands but are not normally palpable.

Where is the posterior triangle located?

the posterior triangle is behind the sternomastoid muscle, with the trapezius muscle on the other side and with its base along the clavicle below.

Where are the sublingual glands located?

the sublingual glands lie in the floor of the mouth.

Where are the submandibular glands located?

the submandibular glands are beneath the mandible at the angle of the jaw.

Where is the temporal artery located?

the temporal artery lies superior to the temporalis muscle; its pulsation is palpable anterior to the ear.

The pregnant woman

the thyroid gland enlarges slightly during pregnancy as a result of hyperplasia of the tissue and increased vascularity

Thyroid gland

the thyroid gland is an important endocrine gland with rich blood supply. It straddles the trachea in the midline of the neck.

Paget's Disease of Bone (Osteitis Deformans)

Askeletal disease of increased bone resorption and formation, which softens, thickens and deforms bone. It affects 10% of those older than 80y/o and occurs more often in males. The disease is characterized by bowed long bones, sudden fractures, frontal bossing and enlarging skull bones press on cranial nerves, causing symptoms of headache, vertigo, tinnitus, progressive deafness, and optic atrophy and compression of the spinal cord.

Facial muscles are mediated by what cranial nerve?

Cranial nerve VII, the facial nerve. Facial muscle function is symmetric bilaterally, except for an occasional quirk or wry expression.

Objective data

Inspect and palpate

Head size

The head size grows during childhood, reaching 90% of its final size when the child is 6 years old.

During infancy

Trunk growth predominates so that head size changes in proportion to body height.

Subjective data

What the patient tells you...ask about headaches, head injury, dizziness, neck pain(limitation of motion), lumps or swelling, history of head or neck surgery

Stroke of cerebrovascular accident

an upper motor neuron lesion (central). A stroke (or brain attack) is an acute neurologic deficit caused by an obstruction of a cerebral vessel, as in atherosclerosis, or a rupture in a cerebral vessel. If you suspect a stroke, ask if the person can smile. Note paralysis of the lower facial muscles, but also note that the upper half of face is not affected because of the intact nerve from the unaffected hemisphere. The person is still able to wrinkle the forehead and close the eyes.

The aging adult-old people Senile tremors

are benign and include head nodding (as if saying yes or no) and tongue protrusion.

Palpate the infant head

as you palpate the newborn's head, the suture lines feel like ridges. By 5 to 6 months, they are smooth and not palpable.

Occipital lymph node

at the base of the skull

2 common variations in the newborn cause the shape of the skull to look markedly asymmetric

caput succedaneum cephalhematoma

Fetal Alcohol Syndrome

characteristic facies include narrow palpebral fissures, epicanthal folds, and midfacial hypoplasia.

Down Syndrome

chromosomal aberration (trisomy 21). Head and face characteristics may include upslanting eyes with inner epicanthal folds; flat nasal bridge, small, broad, flat nose; protruding, thick tongue; ear dysplasia; short, broad neck with webbing; and small hands with single palmar crease.

Allergic Salute Crease

chronically using hand to push the nose up and back, the transverse line on the nose.

Deep cervical chain lymph nodes

deep under the sternomastoid muscle

The pregnant woman 2

during the second trimester, cholasma may show on the face. This is blotchy, hyperpigmented area over the cheeks and forehead that fades after delivery. The thyroid gland may be palpable normally during pregnancy.

Cushing Syndrome

excessive secretion of corticotropin hormone (ACTH) and chronic steroid use, the person develops a plethoric, rounded, "moonlike" face; prominent jowls; red cheeks; hirsutism on the upper lip, lower cheeks, and chin; and acneiform rash on the chest.

Acromegaly

excessive secretion of growth hormone from the pituitary gland after puberty creates an enlarged skull and thickened cranial bones. Note the elongated head, massive face, prominent nose and lower jaw, heavy eyebrow ridge and coarse facial features, especially when compared with the same woman's face on the right pictured several years before she had a pituitary tumor.

Atopic (Allergic) Facies

exhausted face, blue shadows below the eyes ("allergic shiners") from sluggish venous return, a double or since cease on the lower eyelids (Morgan's lines), central facial pallor, and open-mouth breathing (allergic gaping). The open-mouth breathing can lead to malocclusion of the teeth and malformed jaw because the child's bones are still forming.

Fontanels

found in infants-these membrane covered "soft spots" allow for growth of the brain during the 1st year. The triangle-shaped posterior fontanel is closed by 1-2 months, and the diamond-shaped anterior fontanel closes between 9months and 2 years.

Cranial Bones

frontal, parietal, occipital, and temporal

Hyperthyroidism

goiter is an increase in the size of the thyroid gland and occurs with hyperthyroidism. Symptoms include nervousness, fatigue, weight loss, muscle cramps, and heat intolerance; signs include tachycardia, SOB, excessive sweating, fine muscle tremor, think silky hair and skin, infrequent blinking, and a staring appearance

Facial bones in children

grow at varying rates, especially nasal and jaw bones

Submandibular lymph node

halfway between the angle and the tip of the mandible

4 areas where lymph nodes are accessible for examination:

head and neck, arms, axillae, and inguinal region

During the fetal period

head growth predominates, head size is greater than chest circumference at birth.

Auscultate the Thyroid gland

if the thyroid is enlarged, auscultate it for the presence of a bruit. This is a soft, pulsatile, whooshing, blowing sound heard best with the bell of the stethoscope. The bruit is not present normally Abnormal finding: a bruit occurs with accelerated or turbulent blood flow, indicating hyperplasia of the thyroid (e.g. hyperthyroidism).

Preauricular lymph node

in front of the ear

Posterior cervical lymph nodes

in the posterior triangle along the edge of the trapezius muscle

Lymph nodes

lymph nodes are small, oval clumps of lymphatic tissue located at intervals along the vessels. Most nodes are arranged in groups, both deep and superficial, in the body.

Infants and Children- Skull

measure an infant's head size with measuring tape at each visit up to age 2 years, then yearly up to age 6. Abnormal findings: note an abnormal increase in head size or failure to grow

Sutures

meshed immovable joints: coronal suture CROWNS the head from ear to ear at the union of the frontal and parietal bones. The saggital suture SEPARATES the head lengthwise between the two parietal bones. The lamboid suture SEPARATES the parietal bones crosswise from the occipital bone.

Submental lymph node

midline, behind the tip of the mandible

Inspect the trachea

normally, the trachea is midline

Observe the infant head

observe the infant head from all angles, not just the front. The contour should be symmetric. Some racial variation occurs in normal head shapes; Nordic children tend to have long heads, and Asian children have broad heads. Abnormal findings: Frontal bulges or "bossing," occur with prematurity or rickets.

Hydrocephalus

obstruction of drainage of CSF results in excessive accumulation, increasing intracranial pressure and enlargement of head

Superficial cervical lymph nodes

overlying the sternomastoid muscle

Palpate the trachea

palpate for any tracheal shift. Place your index finger on the trachea in the sternal notch, and slip it off to each side. The space should be symmetric on both sides. Note any deviation from the midline. Abnormal findings: conditions of tracheal shift the trachea is pushed to the unaffected (or healthy) side with an aortic aneurysm, a tumor, unilateral thyroid lobe enlargement, and pneumothorax. The trachea is pulled toward the affected (diseased) side with large atelectasis, pleural adhesions, or fibrosis. Tracheal tug is a rhythmic downward pull that is synchronous with systole and that occurs with aortic arch aneurysm.

Palpate temporal area

palpate the temporal artery above the zygomatic (cheek) bone between the eye and top of the ear. Palpate the TMJ as the person opens the mouth, and note normally smooth movement with no limitation or tenderness. Abnormal findings: the artery looks tortuous, feels hardened and tender with temporal arteritis. TMJ- crepitation, limited ROM, or tenderness

Inspect the Thyroid gland

position a standing lamp to shine tangentially across the neck to highlight any possible swelling. Supply the person with a glass of water, and first inspect the neck as the person swallows. Thyroid tissue moves up with a swallow.

Parotid Gland Enlargement

rapid painful inflammation of the parotid occurs with mumps. Parotid swelling also occurs with blockage of a duct, abscess, or tumor. Note swelling anterior to lower ear lobe. Stensen duct obstruction can occur in aging adults dehydrated from diuretics or anticholinergics.

Inspect the skull

size and shape: note the general size and shape; NORMOCEPHALIC is the term that denotes a round symmetric skull that is appropriately related to body size. "normal" includes a wide range of sizes. Abnormal Findings: microcephaly, abnormally small head; macrocephaly, abnormally large head (hydrocephaly, acromegaly, Paget's disease.

Pilar Cyst (Wen)

smooth, firm, fluctuant swelling on the scalp that contains sebum and keratin. Tense pressure of the contents causes overlying skin to be shiny and taut. It is a benign growth.

Posterior auricular (mastoid) lymph node

superficial to the mastoid process

Palpate the Thyroid gland- Anterior approach

this is an alternate method and is more awkward to perform. Standing in front of the person ask them to tip the head forward and to the right. Use your right thumb to displace the trachea slightly to the person's right. Hook your left thumb and fingers around the sternomastoid muscle. Feel for lobe enlargement as the person swallows.

Congenital Hypothyroidism

thyroid deficiency at an early age produces impaired growth and neurologic deficit. Without neonatal screening, characteristic facies develop 3 to 6 months of age: low hairline, hirsute forehead, swollen eyelids, narrow palpebral fissures, widely spaced eyes, depressed nasal bridge, puffy face, thick tongue protruding through an open mouth, and a dull expression. Head size is normal, but the anterior and posterior fontanels are wide open.

Palpate the skull

to assess shape place your fingers in the person's hair and palpate the scalp. The skull normally feels symmetric and smooth. cranial bones that have normal protrusions are the forehead, the side of each parietal bone, the occipital cone and the mastoid process behind the ear. There is NO tenderness to palpation. Abnormal findings: note lumps, depressions, or abnormal protrusions

Palpate the Thyroid gland- Posterior approach

to palpate, move behind the person, use the fingers of your left hand to push the trachea slightly to the right. Then curve your right fingers between the trachea and the sternomastoid muscle, retracting it slightly, and ask the person to take a sip of water. The thyroid moves up under your fingers with the trachea and larynx as the person swallows. Reverse the procedure for the left side. usually you cannot palpate the normal adult thyroid, the lateral lobes usually are not palpable; check them for enlargement, consistency, symmetry, and the presence of nodules. Abnormal findings: look for diffuse enlargement or a nodular lump. Enlarged lobes that are easily palpated before swallowing or are tender to palpation; or the presence of nodules or lumps.

Jugulodigastric lymph node

under the angle of the mandible