Head and Neck

Salivary Glands

1.) produce saliva → to moisten mouth, prevent caries, initiate digestion of carbs

2.) parotid gland: anterior to ear, above mandible; submandibular gland: medial to mandible at angle of jaw; sublingual gland: anterior in floor of mouth

Posterior triangle formed by

1.) trapezius muscle

2.) SCM

3.) clavicle

Anterior triangle formed by

1.) medial border of SCM

2.) mandible

Thyroid

1.) largest endocrine gland → produces 2 hormones: T3 (triiodothyronine) and T4 (thyroxine)

2.) located at each side of the trachea and joined by the isthmus below the cricoid cartilage

Infants

1.) cranial bones are soft and separated by sutures, sutures and fontanels permit skull expansion to accommodate brain growth → sutures ossify 6-18 yrs; fontanels close → 2 months to 2 years

2.) skull molding from birth through vaginal canal → skull bones shift and overlap, normal shape and size resumed within days

Children and Adolescents

subtle changes in facial appearances throughout childhood, male adolescent facial changes —> nose and thyroid cartilage enlarge, facial hair appears

pregnant women

1.) changes in thyroid gland and hormones → fetal thyroid glands become functional in the second trimester, mother is source of thyroid hormone before;

2.) pregnant women require increased iodine intake, as long as adequate iodine intake is maintained, the size of the thyroid will not change by physical examination → slight enlargement may be detectible by ultrasound

Older adults

rate of T4 production and degradation gradually decreases with age, thyroid becomes more fibrotic

percussion

1.) not routinely performed on head and face → one exception

2.) Chovostek sign → percussion on the masseter muscle may produce a hyperactive massenteric reflex → due to hypocalcemia, hypercalcemia, normal calcium

Auscultation

1.) temporal artery → not usually the rest of the skull

2.) bruit —> intracranial bruits are considered common in childhood, and uncommon in neonates; bruit is highly suggestive of a vascular anomaly, ind. who have developed diplopia may rarely have a bruit or blowing sound over the orbit indicating an expanding cerebral aneurysm, can be associated with temporal arteritis

TMJ

1.) palpate → tenderness, decreased ROM / abnormal motion

2.) listen for —> crepitus, clicking, locking

3.) crepitus —> osteoarthritis; clicking → worn, displaced disc

Neck inspection

1.) muscle symmetry, alignment of trachea, landmarks of triangles, fullness at base of neck, masses, webbing

2.) unusual shortness, asymmetry, carotid artery prominence, jugular vein distention, ROM

Neck palpation

tracheal alignment, smoothness and tenderness —> hyoid bone, thyroid cartilage, cricoid cartilage

Tracheal tug

downward displacement of the trachea with each ventricular contraction → suggests presence of aortic aneurysm

Cardarelli sign

push thyroid cartilage to the left, pulsations felt are from aortic aneurysm

Oliver sign

1.) gently grasp cricoid and lift upward, patient extends head

2.) downward tug is felt due to aortic aneurysm

Thyroid Gland: auscultation

1.) if thyroid gland is enlarged, auscultate for vascular sounds

2.) hypermetabolic state → blood supply is dramatically increased and a vascular bruit, a soft rushing sound may be heard

Infants: inspection

1.) head circumference, head symmetry of shape, fontanels, scalp scaling or crusting, dilated scalp veins

2.) hair and hair line; caput succedaneum (not under suture lines), cephalhematoma (bleeding under scalp, under suture lines)

3.) head control, position, movement

Infants: palpation

1.) suture lines, and fontanels

2.) craniotabes: softening of the outer table of the skull

3.) neck muscle tone and masses, trachea, thyroid gland, clavicle → can be broken during birth

transillumination

1.) suspected intracranial lesions or a rapidly decreasing head circumference

2.) performed less often —> CT scan preferred

Children

1.) percussion of skull with one finger to detect macewen sign → stronger resonant sound when either hydrocephalus or a brain abscess is present

2.) bruits common in children up to 5 years of age or in children with anemia

3.) thyroid may or may not be palpated

pregnant women: inspection

inspect chloasma (mask of pregnancy), palpate for hypertrophy of thyroid, auscultate for thyroid bruit

Older Adults: inspection

1.) facies vary with nutritional status → sunken eyes, eyelids loose and wrinkled; evaluate ROM of neck → pain or crepitus, jerkiness or limited movement

2.) palpate thyroid for nodules or irregularities → thyroid more fibrotic as individual ages, feels more nodular or irregular on palpation

3.) gritty = sign of inflammation

Salivary gland tumor

1.) most commonly in parotid → slow growing, painless lump, either in front of ear or under jaw

2.) difficulty opening mouth, tongue numbness or weakness, benign tumors usually smooth, malignant often irregular

3.) facial weakness, fixation of the lump, sensory loss and ulceration

Hypothyroidism

1.) #1 cause worldwide is iodine deficiency → may have normal size thyroid, goiter or nodules → pituitary senses deficiencies and secretes TSH = thyroid growth

2,) primary: thyroid gland doesn’t produce enough thyroid hormone; secondary: inadequate secretion of TSH from pituitary gland or TRH from hypothalamus causes insufficient thyroid hormones

3.) warm climate, weight gain, lethargic, complacent, coarse hair with tendency to break, thick fingernails, eye puffiness, no goiter, no change in cardiac function, constipation, menorrhagia, lethargic but good muscular strength

Myxedema

1.) cognitive impairment, slowed mentation, poor concentration, decreased short-term memory, social withdrawl, psychomotor retardation, depression, apathy

2.) constipation, muscle pain, hearing problem, coarse thick skin, thick nose, swollen lips, puffiness around eyes, slow speech, weight gain, thin brittle hair, bald patches

Hypothyroidism in infant

cretinism → iodine deficiency

Graves Disease

1.) nervous and irritable, weight loss, heat intolerance, thin, warm, moist skin and fine hair, light menstrual flow, rapid pulse and palpitation, tremors

2.) overactive thyroid caused by autoimmune antibodies to thyroid stimulating hormone receptor; stimulates increased hormone production and thyroid growth and goiter

3.) pituitary senses increases hormone and stops TSH but TSI continues growth

Hashimoto Disease

1.) autoimmune antibodies against thyroid gland, destruction of the thyroid gland

2.) hypothyroidism, enlarged, non-tender, smooth goiter

Thyroglossal duct cyst

1.) remnant of fetal development → can be a sinus, fistual or cyst; arises from foramen cecum at junction of anterior two-thirds and posterior third of tongue

2.) palpable, freely moveable cystic mass in the neck, tenderness, redness, swelling in midline of neck

3.) difficulty swallowing or breathing, moves upward with tongue protrusion and swallowing, may have small opening in skin with drainage of mucus

Brachial cleft cyst

1.) congenital lesion formed by incomplete involution of brachial cleft, epithelium lined cyst with or without a sinus tract to overlying skin

2.) painless mass in lateral neck, may have intermittent swelling and tenderness, discharge if sinus tract is present

3.) oval, moderately moveable, smooth, nontender, fluctuant mass along anteromedial border of SCM, usually asymptomatic, if infected → tenderness and erythema

Laryngocele

air sac connected to larynx → most commonly men, 50-60 years old

torticollis (wry neck)

1.) excessive contraction of SCM, birth trauma, tumors, trauma, intrauterine malposition, cranial nerve palsy, muscle spams, infection, drug ingestion

Encephalocele

1.) neural tube defect with protrusions of brain and membranes that cover it through openings in the skull

2.) failure of the neural tube to close completely during fetal development, can occur any place on the scalp

3.) genetic component: often occurs in families with a history of spina bifida or anencephaly

Hydrocephalus

1.) problem in the formation, flow, or absorption of cerebrospinal fluid that leads to increase in volume of the CSF

2.) congenital malformations, congenital infections; acquired abnormalities → intracranial mass, intracranial hemorrhage, meningitis, and trauma

craniosynostosis

1.) premature closing of one or more cranial sutures before brain growth is complete

2.) leads to misshapen skull