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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.