Chapter 14 : Head, Face, and Lymphatics

skull

rigid bony box that protects the brain and special sense organs; includes bones of the cranium and face

cranial bones

frontal, parietal, occipital, temporal

sutures

Areas where the cranial bones have joined together

coronal suture

the suture between the parietal and frontal bones of the skull

sagittal suture

suture between the two parietal bones

lambdoid suture

suture between parietal bones and occipital bone

facial bones

bones of the face: lacrimal, mandibular, maxillary, nasal, vomer, and zygomatic; articulate at sutures

cervical

The cranium is supported by the \__________ vertebrae: C1, the “atlas”; C2, the “axis”; and down to C7

vertebra prominens

spinous process of C7

meninges

Inside the skull the brain is held by membranous \___________; these suspend and support the brain and are shock absorbers in case of trauma

face

has many appearances and expressions that reflect mood; the expressions are formed by the facial muscles, which are mediated by cranial nerve VII, the facial nerve

cranial nerve VII

facial nerve

cranial nerve V

controls trigeminal nerve(jaw)

cranial nerve XI

controls sternocleidomastoid and trapezius muscles (neck)

symmetric

Facial structures are \__________; the eyebrows, eyes, ears, nose, and mouth appear about the same on both sides

salivary glands

Glands of the mouth that produce saliva, a digestive secretion

parotid gland

salivary gland within the cheek, just anterior to the ear; largest of the salivary glands but not usually palpable

submandibular gland

a salivary gland inside the lower jaw on either side that produces most of the nocturnal saliva

sublingual gland

salivary gland under the tongue

temporal artery

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

neck

delimited by the base of the skull and inferior border of the mandible above and by the manubrium sterni, the clavicle, the first rib, and the first thoracic vertebra below

internal, external

The \__________ carotid artery branches off the common carotid and runs inward and upward to supply the brain; the \__________ carotid artery supplies the face, salivary glands, and superficial temporal area

neck muscles

sternomastoid and trapezius

Sternomastoid

muscle extending from sternum to side of the neck; used for turning the head

trapezius

Muscle that covers the back of the neck and upper and middle region of the back; rotates and controls swinging movements of the arm.

spinal accessory

The major neck muscles are the sternomastoid and the trapezius (Fig. 14.4); they are innervated by cranial nerve XI, 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

posterior triangle

behind the sternomastoid muscle, with the trapezius muscle on the other side and its base along the clavicle below; contains the posterior belly of the omohyoid muscle

thyroid gland

endocrine gland that surrounds the trachea in the neck; synthesizes and secretes thyroxine (T4) and triiodothyronine (T3), hormones that stimulate the rate of cellular metabolism

thyroid cartilage

A firm prominence of cartilage that forms the upper part of the larynx; the Adam's apple.

cricoid cartilage

the ring-shaped structure that forms the lower portion of the larynx

lymph nodes

Bean-shaped filters that cluster along the lymphatic vessels of the body. They function as a cleanser of lymph as wells as a site of T and B cell activation

Preauricular

lymph node in front of ear

posterior auricular (mastoid)

lymph node superficial to the mastoid process

occipital

lymph node at the base of the skull

Submental

lymph node midline, behind the tip of the mandible

submandibular

lymph node halfway between the angle and the tip of the mandible

jugulodigastric (tonsillar)

lymph node under the angle of the mandible

superficial cervical

lymph node overlying the sternomastoid muscle

deep cervical

lymph node deep under the sternomastoid muscle

posterior cervical

lymph node in the posterior triangle along the edge of the trapezius muscle

Supraclavicular

lymph node just above and behind the clavicle, at the sternomastoid muscle

drainage patterns

When nodes are enlarged, check the area they drain for the source of the problem. Explore the area proximal (upstream) to the enlarged node. All head and neck structures eventually drain into the deep cervical chain.

lymphatic system

Composed of a network of vessels, ducts, nodes, and organs. Provides defense against infection by detecting and eliminating foreign substances from the body

head and neck

The greatest supply of lymph nodes is located where?

Fontanels

Gaps between a baby's skull that slowly close up during the first 18 months of life

coronal, straight

What two sutures are open in infants to allow growth of the brain?

triangle, diamond

The \________-shaped posterior fontanel is closed by 1 to 2 months, and the \_________-shaped anterior fontanel closes between 9 months and 2 years

6

The head size grows during childhood, reaching 9

1

or 11

thyroid

The \_________ gland enlarges slightly during pregnancy as a result of hyperplasia of the tissue and increased vascularity

less, sags

The facial bones and orbits appear less/more prominent, and the facial skin \_______ as a result of decreased elasticity, decreased subcutaneous fat, and decreased moisture in the skin

headache

leading cause of acute pain and lost productivity, as well as a leading reason for seeking care in outpatient offices, urgent care centers, and emergency departments; classified by etiology, but misdiagnosis is common

chronic migraine

-migraines on 15 days of the month greater than 3 months-possible over use or analgesia migraine medications "rebound"-obesity-caffeine over use

headache

-Any unusually frequent or unusually severe headaches?• Onset. When did this kind of headache start?• Gradual, over hours or a day?• Or 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, like a band around the head, in the sinus area, or in the occipital area?-Is the pain localized on one side or all over?-Character. Throbbing (pounding, shooting) or aching (viselike, constant pressure, dull)?-Is it mild, moderate, or severe?-Course and duration. What time of day do the headaches occur: morning, evening, awaken you from sleep?\How long do they last? Hours, days?Have you noted any daily headaches or several within a time period?-Precipitating factors. What brings it on: activity or exercise, work environment, emotional upset, anxiety, alcohol?-Associated factors. Any relation to other symptoms: any nausea and vomiting? (Note which came first, headache or nausea.) Any vision changes, pain with bright lights, neck pain or stiffness, fever, weakness, moodiness, stomach problems?-Do you have any other illnesses?-Do you take any medications?-What makes it worse: movement, coughing, straining, exercise?-Pattern. Any family history of headache?-What is the frequency of your headaches: once a week? Are your headaches occurring closer together?• Are they getting worse? Or are they getting better?• (For females) When do they occur in relation to your menstrual periods?-Effort to treat. What seems to help: going to sleep, medications, positions, rubbing the area?-Patient-centered care. How have these headaches affected your self-care or your ability to function at work, home, and socially? What do you need to help you cope?

head injury

-Any head injury or blow to your head?-Onset. When? Please describe exactly what happened.-Setting. Any hazardous conditions? Were you wearing a helmet or hard hat?-How did you feel just before injury: dizzy, light-headed, had a blackout, had a seizure?-Lose consciousness and then fall? (Note which came first.)-Knocked unconscious? Or did you fall and lose consciousness a few minutes later?-Any history of illness (e.g., heart trouble, diabetes, epilepsy)?-Location. Exactly where did you hit your head?-Duration. How long were you unconscious? Any symptoms afterward—headache, vomiting, projectile vomiting? Any change in level of consciousness after injury: dazed or sleepy?-Associated symptoms. Any pain in the head or neck, vision change, discharge from ear or nose—is it bloody or watery? Are you able to move all extremities? Any tremors, staggered walk, numbness, and tingling?-Pattern. Are symptoms worse, better, unchanged since injury?-Effort to treat. Emergency department or hospitalized? Any medications?

concussion

violent shaking up or jarring of the brain

dizziness

-Experienced any dizziness?Tell me what you mean by dizziness. Describe it for me.-Associated factors. Any nausea and vomiting, pallor, immobility, decreased hearing acuity, or tinnitus along with the dizziness? Any palpitations or shortness of breath?

Presyncope

a light-headed, swimming sensation or feeling of fainting or falling caused by decreased blood flow to brain or heart irregularity causing decreased cardiac output

vertigo

true rotational spinning often from labyrinthine-vestibular disorder in inner ear

Disequilibrium

shakiness or instability when walking related to musculoskeletal disorder or multisensory deficits

orthostatic hypotension

can cause dizziness: when the difference of BP from sitting to standing is 2

neck pain

-Any neck pain?-Onset. How did the pain start: injury, automobile accident, after lifting, from a fall? Or with fever? Or did it have a gradual onset?-Location. Does pain radiate? To the shoulders, arms?-Associated symptoms. Any limitations to range of motion (ROM), numbness or tingling in shoulders, arms, or hands?-Precipitating factors. Which movements cause pain? Do you need to lift or bend at work or home?-Does stress seem to bring it on?-Patient-centered care. Able to do your work, sleep? What do you need to help you cope?

nuchal rigidity

resistance to flexion of the neck; clinical manifestation of meningitis

lumps or swelling

Recent infection, tenderness? Duration? Change in size? History of irradiation of head, neck, upper chest? Difficulty swallowing? Do you smoke? Do you drink alcohol? Thyroid problems?

dysphagia

condition in which swallowing is difficult or painful

history of head or neck surgery

Ever had surgery of head or neck? Why? When? How do you feel about the results?

additional history for aging adult

1. Patient-centered care. If dizziness is a problem, how does this affect your daily activities? Are you able to drive safely, maneuver about the house safely?2. If neck pain is a problem, how does this affect your daily activities? Are you able to turn head while driving, perform at work, do housework, sleep, look down when using stairs?

Normocephalic

refers to round symmetric skull that is appropriately related to body size

size and shape

-Normocephalic-Assess shape: Place fingers in person's hair and palpate scalp-Cranial bones that have normal protrusions: forehead, lateral edge of parietal bones, occipital bone, and mastoid process behind each ear

temporal area

-Palpate temporal artery above cheek bone between eye and top of ear-Palpate the temporomandibular joint

facial structures

-Should always be symmetric-Eyebrow, palpebral fissure, nasolabial folds, sides of mouth-Not expression and appropriateness to behavior or reported mood-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

Head and Neck Symmetry

Head position is centered in midline, and accessory neck muscles should be symmetricalHead should be held erect and still

range of motion

-Note any limitations-Test muscle strength-Observe for enlargement of glands and/or pulsations

trachea

midnline, no deviaion

carotid artieries

used for CPR to check pulse

jugular veins

check for distention- used as a sign of heart failure on the right side (left sided heart failure shows in the lungs)

lymph nodes

-Palpate nodes noting location, size, shape, delimitation, mobility, consistency, and tenderness

Examining Lymph Nodes

○ Using a gentle circular motion of finger pads, palpate lymph nodes
○ Beginning with preauricular lymph nodes in front of ear, palpate the 1

trachea

-Should be midline-Palpate for any tracheal shift-Note any deviation from midline

thyroid gland

-Difficult to palpate; check for enlargement, consistency, symmetry, and presence of nodules-Position patient for best approach (posterior or anterior)-Auscultate thyroid for bruit, if enlarged

bruit

turbulent flow to that area

Hyperthyroidism (Graves Disease) Physical presentation of neck and face include:

-Goiter-Eyelid retraction-ExophthalmosAn autoimmune disease with increased production of thyroid hormones causes an increased metabolic rate

signs/symptoms of hypothyroidism

- Sleepiness- Cold intolerance- Weight gain (especially unintentional)- Muscle aches- Fatigue- Menstrual irregularities- Pale, dry skin- This, brittle hair or nails- Bradycardia- Constipation- Edema (especially periorbital)- Difficulty with concentration and memory- Slowing of relaxation phase of tendon reflexes- May have higher diastolic blood pressure

myxedema

caused by extreme deficiency of thyroid secretion; also known as adult hypothyroidism

signs/symptoms of hyperthyroidism

- Nervousness- Fatigue- Weakness- Palpitations- Heat intolerance- Excessive sweating- Dyspnea- Diarrhea- Insomnia- Poor concentration- Oligomenorrhea- Weight loss- Hair loss- Tachycardia- Proximal myopathy- Warm, moist skin- Hyperkinesis- Stare, lid lag, lid retraction, and exophthalmos (with Grave’s Disease)- Emotional liability- Hyperactive reflexes- Thyroid enlargement (in most cases)

hyperthyroidism myxedema

Physical presentation of neck and face include:-Puffy edematous face-Periorbital edema-Coarse facial features-Coarse hair and eyebrowsA deficiency of thyroid hormone. This reduces the metabolic rate and, when severe, causes a nonpitting edema or myxedema

physical examination: 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• During examination, direct aging person to perform ROM slowlyo He or she may experience dizziness with side movements• Aging person may have prolapse of submandibular glands, which may be mistaken for a tumor; but drooping submandibular glands will feel soft and be present bilaterally

isolated head tumors

benign and include head nodding and tongue protrusion

Findings in Older Adults

•Older clients who have arthritis or osteoporosis may experience neck pain and a decreased ROM.
•In older clients, facial wrinkles are prominent because subcutaneous fat decreases with age. In addition, the lower face may shrink and the mouth may be drawn inward as a result of resorption of mandibular bone, also an age-related process.
•The strength of the pulsation of the temporal artery may be decreased in the older client.
•In older clients, cervical curvature may increase because of kyphosis of the spine. Moreover, fat may accumulate around the cervical vertebrae (especially in women). This is sometimes called a “dowager’s hump.”
•Older clients usually have somewhat decreased flexion, extension, lateral bending, and rotation of the neck. This is usually due to arthritis.
•If palpable, the older client’s thyroid may feel more nodular or irregular because of fibrotic changes that occur with aging; the thyroid may also be felt lower in the neck because of age-related structural changes.

caput succedaneum

diffuse edema of the fetal scalp that crosses the suture lines. reabsorbes within 1 to 3 days

Cephalhematoma

subperiosteal hemorrhage, a result of birth trauma, appears several hours after birth and gradually increases in size; will be reabsorbed during first few weeks of life without treatment

positional plagiocephaly

flattening of one side of an infant's head from prolonged lying in one position

tonic neck reflex

turning the head to one side, extending the arm and leg on that side, and flexing the limbs on the opposite side

isolated head tremors

benign and include head nodding and tongue protrusion

tension headache

- nonmigraine headache in which pain is felt in all or part of the head- gradual onset, lasts 3

migraine

- severe, recurring, unilateral, vascular headache- rapid onset, lasts 4-72 hr

cluster headache

- Unilateral, severe periorbital headache with tearing and conjunctival erythema.- abrupt onset, lasts 45-9

congenital torticollis

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

simple diffuse goiter (SDG)

Endemic goiter, a chronic enlargement of the thyroid gland, is common in wide regions of the world (especially mountainous regions) where the soil is low in iodine