Chapter 14: Head, Face, Neck, and Regional Lymphatics
Chapter 14: Head, Face, and Neck, and Regional Lymphatics
Structure and Function: Head (1 of 2)
The skull serves as a rigid box that protects the brain.
Composed of:
Bones of the cranium
Bones of the face
Supported by cervical vertebrae.
Cranial bones include:
Frontal
Parietal
Occipital
Temporal
Sutures: Points where adjacent cranial bones mesh include:
Coronal
Sagittal
Lambdoid
Structure and Function: Head (2 of 2)
Facial bones: There are 14 facial bones that also articulate at sutures.
Facial expressions are formed by facial muscles, which are mediated by cranial nerve VII (the facial nerve).
Salivary glands: Two pairs accessible for examination on the face:
Parotid glands: Located in cheeks over mandible, anterior to and below the ear; largest of salivary glands; generally not palpable.
Submandibular glands: Found beneath the mandible at the angle of the jaw.
Sublingual glands: Located in the floor of the mouth.
The temporal artery is situated superior to the temporalis muscle, and its pulsation is palpable anterior to the ear.
Structure: Head
Facial Structures:
Frontal bone
Nasal bone
Lacrimal bone
Maxilla
Mandible
Parietal bone
Lambdoid suture
Occipital bone
Temporal bone
Sphenoid bone
Zygomatic bone
External acoustic meatus
Mastoid process
Temporomandibular joint
C1, Atlas
C2, Axis
C7, vertebral prominens
Structure and Function: Neck
The neck is delimited by:
Base of skull
Inferior border of mandible above
Manubrium sterni, clavicle, first rib, first thoracic vertebra below.
The neck acts as a conduit for various structures:
Vessels
Muscles
Nerves
Lymphatics
Viscera of the respiratory and digestive systems.
The internal carotid artery branches off the common carotid and runs inward and upward to supply the brain.
The external carotid artery supplies the:
Face
Salivary glands
Superficial temporal area.
Structure and Function: Neck Muscles
Major neck muscles include:
Sternomastoid: Innervated by cranial nerve XI.
Enables head rotation and flexion.
Divides the neck into anterior and posterior triangles.
Trapezius: Innervated by cranial nerve XI.
Functions to move shoulders and extend/turn head.
Structure and Function: Thyroid
The thyroid gland is an endocrine gland that:
Straddles the trachea in the middle of the neck.
Synthesizes and secretes:
Thyroxine (T4)
Triiodothyronine (T3)
Both hormones stimulate the rate of cellular metabolism.
The gland consists of:
Two lobes connected by a thin isthmus.
Above the isthmus is the cricoid cartilage or upper tracheal ring.
Thyroid cartilage:
Features a small palpable notch in the upper edge, often referred to as the “Adam’s apple” in males.
Structure and Function: Lymphatics
The lymphatic system is a major part of the immune system.
Its primary function is to detect and eliminate foreign substances from the body.
The head and neck have a rich supply of lymph nodes:
The greatest concentration of lymph nodes is in the head and neck region.
Lymphatic drainage helps to prevent potentially harmful substances from entering the circulation.
Understanding the direction of drainage patterns of lymph nodes is essential.
Drainage Patterns of Lymph Nodes
Preauricular lymph nodes: Located in front of the ear.
Posterior auricular (mastoid) lymph nodes: Superficial to the mastoid process.
Occipital lymph nodes: Located at the base of the skull.
Submental lymph nodes: Found midline, behind the tip of the mandible.
Submandibular lymph nodes: Situated halfway between the angle and tip of the mandible.
Jugulodigastric (tonsillar) lymph nodes: Positioned under the angle of the mandible.
Superficial cervical lymph nodes: Overlying the sternomastoid muscle.
Deep cervical lymph nodes: Deep under the sternomastoid muscle.
Posterior cervical lymph nodes: Located in the posterior triangle along the edge of the trapezius muscle.
Supraclavicular lymph nodes: Found just above and behind the clavicle, at the sternomastoid muscle.
Locations of Lymph Nodes
Detailed anatomical locations of lymph nodes include:
Preauricular
Posterior auricular
Occipital
Submental
Submandibular
Jugulodigastric
Superficial cervical
Deep cervical chain
Posterior cervical
Supraclavicular
Developmental Competence: Infants and Children (1 of 2)
Bones of the neonatal skull are separated by sutures and fontanels, which are:
Membrane-covered “soft spots” allowing for brain growth during the first year and gradually ossifying.
Closure of fontanels:
Triangle-shaped posterior fontanel closes by 1 to 2 months.
Diamond-shaped anterior fontanel closes between 9 months and 2 years.
During the fetal period, head growth predominate:
Head size is greater than chest circumference at birth, reaching 90% of final size by 6 years old.
Developmental Competence: Infants and Children (2 of 2)
During infancy, trunk growth predominates:
Head size changes in proportion to body height.
Facial bones grow at varying rates:
In infants, mandible and maxilla are small with a low nasal bridge.
Lymphoid tissue:
Well developed at birth; reaches adult size by age 6.
In adolescence, changes include:
Appearance of facial hair in boys (first on upper lip, then cheeks and lower lip, finally chin).
Noticeable enlargement of thyroid cartilage causes deepening of voice.
Developmental Competence
In pregnant females, the thyroid gland enlarges slightly during pregnancy due to hyperplasia of tissue and increased vascularity.
In the aging adult:
Facial bones and orbits appear more prominent.
Facial skin sags due to decreased elasticity, subcutaneous fat, and moisture content.
Lower face may look smaller if teeth have been lost.
Genetics and Environment: Headache
Headache: Leading cause of acute pain and lost productivity; classified by etiology and often misdiagnosed.
Types include:
Tension-type headaches (TTH): The most common
Migraine: The second most common
Headaches can be episodic or chronic.
Identify triggers: Environmental factors, foods, and/or stress contribute to headaches.
Headaches impact productivity and affect activities of daily living (ADLs).
Subjective Data: Health History
Inquire about:
Headaches
Head injury
Dizziness
Neck pain or limitation of motion
Lumps or swelling
History of head or neck surgery
Health History Questions: Headaches
Essential inquiries include:
Onset pattern and characteristics
Location and pattern
Pain characteristics
Course and duration
Precipitating factors
Associated factors
Alleviating factors and what exacerbates the condition
Presence of comorbidities
Medication history
Focus on patient-centered care.
Health History Questions: Head Injury
Questions should cover:
Onset, setting, and description of injury
Changes in consciousness level (loss of consciousness and/or falls)
History of comorbidity
Location of injury
Duration/pattern of symptoms and associated symptoms
Treatment plan including emergency, hospitalization, or medication.
Other Health History Questions
For dizziness:
Ask for a description of the sensation in the patient’s own words.
Explore any associated symptoms like change of position, nausea, or vomiting.
For neck pain:
Inquire about onset, location, associated symptoms, limitation of range of motion (ROM), precipitating factors, and stress.
For lumps or swelling:
History of recent infection, radiation exposure, smoking, alcohol use, difficulty swallowing, or thyroid issues.
History of head or neck surgery should include:
Type, reason for surgery, and response to surgery.
Additional Health History Questions
For infants and children:
Inquire about maternal alcohol or drug use.
Type of delivery (vaginal or cesarean) and any complications (e.g., use of forceps).
Discuss growth patterns and reaching developmental milestones.
For aging adults:
Focus on patient-centered care:
Effects of dizziness and/or neck pain on daily activities.
Physical Examination: Inspect and Palpate the Skull
Assess size and shape:
Normocephalic: Round and symmetric.
Evaluate shape by palpating the scalp through hair with fingers.
Cranial bones with normal protrusions include:
Forehead
Lateral edge of parietal bone
Occipital bone
Mastoid process behind each ear.
Temporal area: Palpate the temporal artery located above the zygomatic (cheek) bone between the eye and the top of the ear.
Inspect the Face
Facial structures should be symmetric in appearance.
Note facial expressions and their appropriateness to behavior or reported mood.
Identify any abnormal facial structures:
Coarse facial features
Exophthalmos
Changes in skin color, pigmentation, or abnormal swellings.
Observe for involuntary movements (tics) in facial muscles; normally, none should be present.
Inspect and Palpate the Neck (1 of 2)
Assess neck symmetry:
The head should be centered in the midline, and accessory neck muscles should be symmetric.
The head must be held erect and still.
Range of motion:
Note any limitations.
Test muscle strength.
Observe for gland enlargement and/or pulsations.
Lymph nodes:
Palpate nodes, noting:
Location
Size
Shape
Delimitation
Mobility
Consistency
Tenderness.
Inspect and Palpate the Neck (2 of 2)
Trachea:
Should be midline; palpate for any tracheal shift.
Note any deviation from midline.
Thyroid gland:
Difficult to palpate; check for:
Enlargement
Consistency
Symmetry
Presence of nodules.
Position patient for optimal approach:
Posterior approach
Anterior approach (alternate method).
Auscultate the thyroid for bruit if enlarged.
Examining Lymph Nodes
Using a gentle circular motion of finger pads, palpate lymph nodes.
Begin with preauricular lymph nodes in front of the ear, systematically palpating the 10 groups of lymph nodes in routine order.
Many nodes are closely packed; thus, a thorough examination is crucial to avoid missing small nodes.
Thyroid Palpation: Anterior Approach
Positioning:
Left thumb palpates the thyroid while the right thumb displaces.
Thyroid Palpation: Posterior Approach
Positioning:
Right hand palpates while the left hand displaces.
Physical Examination: Infants and Children (1 of 2)
Skull Measurement: Measure the infant's head at each visit up to age 2 years and yearly until age 6 years.
Observe head posture and control:
Infants can turn their heads side to side by 2 weeks.
Variations in newborns that may affect skull shape due to birth trauma:
Caput succedaneum: Edematous swelling that extends across suture lines; self-limiting.
Cephalohematoma: Defined subperiosteal hemorrhage over one cranial bone, reabsorbed within the first few weeks of life.
Physical Examination: Infants and Children (2 of 2)
Skull Molding: Overriding of cranial bones during birth that resolves within a few days or weeks.
Positional molding (positional plagiocephaly):
Flattening of the head due to sleeping position.
Fontanels: Observe anterior and posterior fontanels.
Head and neck control:
Assess the appearance of tonic neck reflex, which should disappear between 3 and 4 months of age.
Physical Examination: Infants and Children: Face
Check facial features for:
Symmetry
Appearance
Swelling.
Note symmetry in wrinkling when the infant cries or smiles (both sides of lips rise; both sides of forehead wrinkle).
Normally, no observable swelling should be evident.
Parotid gland enlargement: Best seen when the child looks up; swelling appears below the angle of the jaw.
Physical Examination: Infants and Children: Neck
An infant's neck appears short, lengthening during the first 3 to 4 years.
Assess muscle development with gentle passive range of motion:
Cradle the infant's head and gently turn it side to side while testing for forward flexion, extension, and rotation.
Note any resistance to movement, especially flexion.
In infancy, cervical lymph nodes are generally not palpable, but in children, lymph nodes can be palpable:
Nodes less than 3 mm are considered normal.
Due to a higher incidence of infection, expect a greater incidence of inflammatory adenopathy; no other mass should occur in the neck.
Infants and Children: Special Procedures
Percussion: With an infant, directly percussion with a plexor finger against the head surface yields a resonant or "cracked pot" sound, normal before closure of fontanels.
Auscultation: Bruits are common in the skull of children under 4 or 5 years or those with anemia:
Systolic or continuous; heard over temporal area.
Physical Examination: Pregnant Females
During the second trimester, chloasma may appear on the face:
A blotchy, hyperpigmented area over the cheeks and forehead, fades after delivery.
The thyroid gland may be palpably enlarged.
Physical Examination: Aging Adults
Temporal arteries may appear twisted and prominent.
In some aging adults, a mild rhythmic tremor of the head may be normal:
Isolated head tremors are benign and may include head nodding and tongue protrusion.
If teeth are lost, the lower face appears unusually small, giving a sunken appearance to the mouth.
The neck may show an increased concave curve due to compensation for kyphosis.
Maintain patient safety by advising slow performance of range of motion and position changes to minimize potential dizziness.
Abnormal Findings: Primary Headaches
Diagnosed by patient history with no abnormal findings on examination or laboratory results.
Types of headaches include:
Tension
Migraine
Cluster
Factors to review:
Definition
Location
Character
Duration
Quantity and severity
Timing and aggravating symptoms or triggers
Associated symptoms and relieving factors
Efforts to treat.
Abnormal Findings: Pediatrics (1 of 2)
Hydrocephalus: Resulting from the obstruction of cerebrospinal fluid drainage leading to excessive accumulation, increased intracranial pressure, and head enlargement.
Down syndrome: The most common chromosomal abnormality characterized by:
Upslanting eyes with inner epicanthal folds
Flat nasal bridge and small, broad nose
Protruding thick tongue and ear dysplasia
Broad neck with webbing and small hands with a single palmar crease.
Plagiocephaly: Positional or deformational characterized by asymmetrical skull shape due to sleeping position.
Abnormal Findings: Pediatrics (2 of 2)
Craniosynostosis: A condition where the premature closure of one or more cranial sutures leads to head malformation.
Atopic (allergic) facies: Presentations in children with chronic allergies include:
Exhausted face
Allergic shiners
Morgan lines
Central facial pallor
Allergic gaping.
Fetal alcohol spectrum disorders (FASD): Features include:
Narrow palpebral fissures
Epicanthal folds
Thin upper lip
Midfacial hypoplasia
Allergic salute and crease: Appearance of a transverse line on the nose due to chronic piggybacking of the hand to push the nose up and back.
Fetal Alcohol Spectrum Disorders (FASD)
Discriminating Features
Short palpebral fissures
Flat midface
Short nose
Indistinct philtrum
Thin upper lip
Epicanthal folds
Low nasal bridge
Minor ear abnormalities (e.g. Micrognathia)
Abnormal Findings: Swellings of Head and Neck
Congenital torticollis: Occurs from hematoma in one sternomastoid muscle, causing head tilt to one side and limited neck range of motion on the opposite side.
Simple diffuse goiter (SDG): Endemic goiter due to iodine deficiency resulting in chronic enlargement of the thyroid gland.
Thyroid – multinodular goiter (MNG): Usually indicates inflammation or multinodular goiter rather than neoplasm, but any rapidly enlarging or firm nodule should be suspected.
Pilar cyst (Wen): A benign growth manifested as a smooth, fluctuant swelling on the scalp.
Parotid gland enlargement: Rapid, painful enlargement seen in response to mumps, blockage of duct, abscess, or tumor.
Thyroid Disorders: Graves Disease
Physical Presentation
Many signs may appear on the neck and face:
Goiter
Eyelid retraction
Exophthalmos
Thyroid Disorders: Hypothyroidism
Physical Presentation
Common features of the neck and face include:
Puffy, edematous face
Periorbital edema
Coarse facial features
Coarse hair and eyebrows
Abnormal Facial Appearances Associated with Chronic Illnesses
Acromegaly: Characterized by:
Elongated head
Massive face
Overgrowth of the nose
Lower jaw protrusion
Heavy eyebrow ridge
Coarse facial features.
Cushing syndrome: Identified by:
Classic “moonlike” face
Red cheeks
Hirsutism.
Bell palsy: Paralysis on one side of the face due to lower motor neuron lesion.
Stroke or brain attack: Leads to upper motor neuron lesion, causing paralysis of lower facial muscles.
Parkinson syndrome: Known for a classic “masklike” appearance:
Elevated eyebrows
Staring gaze
Oily skin and drooling due to dopamine deficiency.
Cachectic appearance: Sunken eyes, hollow cheeks, and a defeated expression accompanying chronic wasting diseases.
Summary Checklist: Head, Face, and Neck, including Regional Lymphatics Examination
Inspect and palpate the skin:
General size and contour.
Note any deformities.
Palpate the temporal artery and temporomandibular joint (TMJ).
Inspect and palpate the face:
Observe facial expression.
Assess cranial nerve VII for symmetry of movement.
Note any abnormal movements.
Inspect and palpate the neck:
Active range of motion.
Assess potential enlargement and position of the trachea.
Auscultate the thyroid (if enlarged) for bruit.