Chapter 14: Head, Face, and Neck, and Regional Lymphatics
Head, Face, and Neck, and Regional Lymphatics: Study Notes
Structure and Function: Head
Skull: A rigid box protecting the brain, supported by cervical vertebrae.
Cranial Bones: Frontal, Parietal, Occipital, Temporal.
Sutures: Adjacent cranial bones mesh at sutures:
Coronal
Sagittal
Lambdoid
Facial Bones: 14 facial bones articulate at sutures.
Facial Expressions: Formed by facial muscles, mediated by cranial nerve VII (facial nerve).
Salivary Glands (Accessible to examination):
Parotid Glands: In cheeks over mandible, anterior to and below ear. Largest, normally not palpable.
Submandibular Glands: Beneath mandible at angle of jaw.
Sublingual Glands: Lies in floor of mouth.
Temporal Artery: Lies superior to temporalis muscle, pulsation palpable anterior to ear.
Structure and Function: Neck
Delimited by:
Superiorly: Base of skull and inferior border of mandible.
Inferiorly: Manubrium sterni, clavicle, first rib, and first thoracic vertebra.
Contents: Vessels, muscles, nerves, lymphatics, and viscera of respiratory and digestive systems.
Carotid Arteries:
Internal Carotid: Branches off common carotid, runs inward/upward to supply the brain.
External Carotid: Supplies face, salivary glands, and superficial temporal area.
Major Neck Muscles (Innervated by cranial nerve XI):
Sternomastoid: Enables head rotation and flexion, divides neck into anterior and posterior triangles.
Trapezius (Two muscles): Move shoulders and extend/turn head.
Structure and Function: Thyroid
Location: Straddles trachea in the middle of the neck.
Function: Endocrine gland that synthesizes and secretes hormones.
Hormones: Thyroxine (T4) and Triiodothyronine (T3), which stimulate the rate of cellular metabolism.
Structure:
Has two lobes, connected in the middle by a thin isthmus.
Above the isthmus is the cricoid cartilage (upper tracheal ring).
Thyroid Cartilage: Small palpable notch in upper edge (‘‘Adam’s apple’’ in males).
Structure and Function: Lymphatics
Role: Major part of the immune system; detects and eliminates foreign substances from the body.
Lymph Nodes: Rich supply, with the greatest concentration in the head and neck.
Help prevent harmful substances from entering circulation.
Important to be familiar with drainage patterns.
Lymph Node Locations:
Preauricular: In front of ear.
Posterior Auricular (Mastoid): Superficial to mastoid process.
Occipital: At base of skull.
Submental: Midline, behind tip of mandible.
Submandibular: Halfway between angle and tip of mandible.
Jugulodigastric (Tonsillar): Under angle of mandible.
Superficial Cervical: Overlying sternomastoid muscle.
Deep Cervical: Deep under sternomastoid muscle.
Posterior Cervical: In posterior triangle along edge of trapezius muscle.
Supraclavicular: Just above and behind clavicle, at sternomastoid muscle.
Developmental Competence: Infants and Children
Skull Bones and Fontanels:
Neonatal skull bones are separated by sutures and fontanels (membrane-covered ‘‘soft spots’’).
Allow for brain growth during the first year; gradually ossify.
Posterior Fontanel: Triangle-shaped, closes by 1 to 2 months.
Anterior Fontanel: Diamond-shaped, closes between 9 months and 2 years.
Head Growth:
During fetal period, head growth predominates.
Head size is greater than chest circumference at birth and reaches 90\% of final size at 6 years old.
During infancy, trunk growth predominates, changing head size proportion to body height.
Facial Bones: Grow at varying rates.
In toddlers, mandible and maxilla are small, and the nasal bridge is low.
Lymphoid Tissue: Well developed at birth, grows to adult size by 6 years old.
Adolescence:
Facial hair appears in boys: first on upper lip, then cheeks and lower lip, last on chin.
Noticeable enlargement of thyroid cartilage (larynx) occurs, and the voice deepens.
Developmental Competence: Pregnant Female
Thyroid Gland: Enlarges slightly during pregnancy due to hyperplasia of tissue and increased vascularity.
Developmental Competence: Aging Adult
Facial Bones and Orbits: May appear more prominent.
Facial Skin: Sags due to decreased elasticity, decreased subcutaneous fat, and decreased skin moisture.
Lower Face: May look smaller if teeth have been lost.
Temporal Arteries: May look twisted and prominent.
Head Tremors: A mild rhythmic tremor of the head may be normal; isolated head nodding and tongue protrusion are benign.
Genetics and Environment: Headache
Leading cause of acute pain and lost productivity.
Often misdiagnosed; classified by etiology.
Types:
Tension-type headaches (TTH): Most common.
Migraine: Second most common; episodic and chronic.
Triggers: Environmental factors, foods, stress.
Impacts daily activities and productivity.
Subjective Data: Health History - Key Areas
Headache
Head injury
Dizziness
Neck pain, limitation of motion
Lumps or swelling
History of head or neck surgery
Health History Questions: Headaches
Onset, Pattern, Characteristics.
Location.
Pain Characteristics.
Course and Duration.
Precipitating Factors.
Associated Factors.
Alleviating Factors (what makes it worse).
Comorbidities.
Medication History.
Patient-Centered Care.
Health History Questions: Head Injury
Onset, Setting, Description of Injury.
Changes in Levels of Consciousness (LOC): Loss of consciousness, fall history.
Comorbidity History.
Location of Injury.
Duration/Pattern of Symptoms.
Associated Symptoms.
Treatment Plan: Emergency, hospitalization, medication.
Other Health History Questions
Dizziness:
Patient’s own words to describe the ‘‘feeling.’’
Associated with change of position, nausea, vomiting.
Neck Pain:
Onset, location, associated symptoms, limitation of Range of Motion (ROM).
Precipitating factors, stress.
Focus on patient-centered care.
Lumps or Swelling:
History of recent infection, radiation exposure, smoking, alcohol use.
Difficulty swallowing (dysphagia).
Thyroid issues.
History of Head or Neck Surgery: Type of surgery, reason, response to surgery.
Additional Health History Questions: Infants and Children
Maternal alcohol or drug use during pregnancy?
Type of delivery (vaginal or cesarean section)? Any difficulty, use of forceps?
Growth pattern?
Reaching developmental milestones?
Additional Health History Questions: Aging Adults
If experiencing dizziness and/or neck pain, how does it affect daily activities?
Inspect and Palpate the Skull
Size and Shape:
Normocephalic: Round and symmetric.
Assess shape by placing fingers in hair and palpating scalp.
Normal Protrusions: Forehead, lateral edge of parietal bones, occipital bone, mastoid process behind each ear.
Temporal Area: Palpate temporal artery above zygomatic (cheek) bone between eye and top of ear.
Inspect the Face
Facial Structures: Should always be symmetric.
Note facial expression and appropriateness to behavior or mood.
Note any abnormal facial structures:
Coarse facial features.
Exophthalmos (protruding eyes).
Changes in skin color or pigmentation.
Abnormal swellings.
Note any involuntary movements (tics) in facial muscles; normally none occur.
Inspect and Palpate the Neck
Head and Neck Symmetry:
Head position centered in midline.
Accessory neck muscles should be symmetric.
Head should be held erect and still.
Range of Motion (ROM):
Note any limitations; test muscle strength.
Observe for enlargement of glands and/or pulsations.
Lymph Nodes:
Palpate nodes noting location, size, shape, delimitation, mobility, consistency, and tenderness.
Trachea:
Should be midline.
Palpate for any tracheal shift; note any deviation.
Thyroid Gland:
Often difficult to palpate.
Check for enlargement, consistency, symmetry, and presence of nodules.
Approaches for Palpation: Posterior approach, Anterior approach (alternate method).
Auscultate for bruit: If thyroid gland is enlarged.
Examining Lymph Nodes: Procedure
Use a gentle circular motion of finger pads.
Begin with preauricular lymph nodes in front of ear.
Palpate all 10 groups of lymph nodes in a routine, systematic order.
Do not vary the sequence to avoid missing small nodes.
Physical Examination: Infants and Children - Skull
Head Measurement: Measure infant’s head at each visit up to age 2 years and yearly up to 6 years.
Head Posture and Control: Infant can turn head side to side by 2 weeks.
Common Newborn Asymmetries from Birth Trauma:
Caput Succedaneum: Edematous swelling that is self-limiting and extends across suture lines.
Cephalohematoma: Subperiosteal hemorrhage, well defined over one cranial bone, reabsorbed during first few weeks of life.
Molding: Overlapping of cranial bones during birth process, resolves over a few days or a week.
Positional Molding (Positional Plagiocephaly): Flattening of the head due to infant sleeping position.
Fontanels: Observe anterior and posterior fontanel for bulging or depression.
Head and Neck Control: Observe for tonic neck reflex (disappears between 3 and 4 months of age).
Physical Examination: Infants and Children - Face
Check facial features for symmetry, appearance, and swelling.
Note symmetry of wrinkling when infant cries or smiles.
Normally, no swelling is evident.
Parotid Gland Enlargement: Best seen when child looks up; swelling appears below the angle of the jaw.
Physical Examination: Infants and Children - Neck
An infant’s neck looks short; it lengthens during the first 3 to 4 years.
Assess muscle development with gentle passive ROM (cradle head, turn side to side, test flexion/extension/rotation).
Note resistance to movement, especially flexion.
Lymph Nodes:
During infancy, cervical lymph nodes are not normally palpable.
In children, palpable nodes less than 3 mm are normal.
Children have a higher incidence of infection, leading to a greater incidence of inflammatory adenopathy; no other mass should occur.
Infants and Children: Special Procedures
Percussion:
Directly percuss with plexor finger against 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 of age, or in children with anemia.
Systolic or continuous; heard over the temporal area.
Physical Examination: Pregnant Female
During the second trimester, chloasma may show on the face (blotchy, hyperpigmented area over cheeks and forehead that fades after delivery).
Thyroid gland may be palpable normally during pregnancy.
Physical Examination: Aging Adult
Temporal arteries: May look twisted and prominent.
A mild rhythmic tremor of the head may be normal, including head nodding and tongue protrusion (benign).
If some teeth have been lost, the lower face looks unusually small, with the mouth sunken in.
Neck: May show an increased concave curve to compensate for kyphosis.
Patient Safety: Encourage slow ROM and position changes to minimize potential for dizziness.
Abnormal Findings: Primary Headaches
Diagnosed by patient history with no abnormal findings on exam or laboratory results.
Types: Tension, Migraine, Cluster.
Factors to Review: Definition, location, character, duration, quantity and severity, timing, aggravating symptoms or triggers, associated symptoms, relieving factors, and efforts to treat.
Abnormal Findings: Pediatrics
Hydrocephalus: Obstruction of cerebrospinal fluid (CSF) drainage leads to excessive accumulation, increasing intracranial pressure and head enlargement.
Down Syndrome: Most common chromosomal abnormality with characteristic facial abnormalities:
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 single palmar crease.
Plagiocephaly: Positional or deformational flattening of the head due to sleeping position.
Craniosynostosis: Premature closing of one or more cranial sutures, leading to head malformation.
Atopic (Allergic) Facies: Variety of presentations in children with chronic allergies:
Exhausted face, allergic shiners, Morgan lines, central facial pallor, and allergic gaping.
Fetal Alcohol Spectrum Disorders (FASD) (Discriminating features):
Short palpebral fissures, flat midface, short nose, indistinct philtrum, thin upper lip.
Associated features: Epicanthal folds, low nasal bridge, minor ear abnormalities, micrognathia.
Allergic Salute and Crease: Appearance of a transverse line on the nose from chronically repeated use of hand to push the nose up and back.
Abnormal Findings: Swellings of Head and Neck
Congenital Torticollis: Hematoma in one sternomastoid muscle (often from intrauterine malposition) results in head tilt to one side and limited neck ROM to the opposite side.
Simple Diffuse Goiter (SDG): Endemic goiter due to iodine deficiency, leading to chronic enlargement of the thyroid gland.
Thyroid—Multinodular Goiter (MNG): Multiple nodules usually indicate inflammation or multinodular goiter rather than a neoplasm; rapidly enlarging or firm nodules require suspicion of neoplasm.
Pilar Cyst (Wen): Benign growth, presents as 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 (Neck and Face):
Goiter
Eyelid retraction
Exophthalmos (bulging eyes)
Thyroid Disorders: Hypothyroidism
Physical Presentation (Neck and Face):
Puffy edematous face
Periorbital edema
Coarse facial features
Coarse hair and eyebrows
Abnormal Facial Appearances Associated with Chronic Illnesses
Acromegaly: Elongated head, massive face, overgrowth of nose, lower jaw, heavy eyebrow ridge, and coarse facial features.
Cushing Syndrome: Classic ‘‘moonlike’’ face, red cheeks, and hirsutism.
Bell Palsy: Paralysis on one side of the face resulting from a Lower Motor Neuron (LMN) lesion.
Stroke or Brain Attack: Upper Motor Neuron (UMN) lesion leading to paralysis of lower facial muscles.
Parkinson Syndrome: Classic ‘‘masklike’’ appearance, elevated eyebrows, staring gaze, oily skin, and drooling due to dopamine deficiency.
Cachectic Appearance: Sunken eyes, hollow cheeks, and defeated expression accompanying chronic wasting diseases.
Summary Checklist: Head, Face, and Neck, Including Regional Lymphatics Examination
Inspect and palpate the skin.
Assess general size and contour of the head, noting any deformities.
Palpate temporal artery and temporomandibular joint (TMJ).
Inspect and palpate the face.
Observe facial expression.
Cranial nerve VII (facial nerve) for symmetry of movement.
Observe for any abnormal movements.
Inspect and palpate the neck.
Active Range of Motion (ROM).
Potential enlargement of glands.
Position of trachea.
Auscultate thyroid (if enlarged) for bruit.