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