Study Notes on Head, Face, Neck, and Lymphatics

CHAPTER 14: HEAD, FACE, AND NECK, AND REGIONAL LYMPHATICS

STRUCTURE AND FUNCTION: HEAD

  • Skull
    • Defined as a rigid box that protects the brain.
    • Comprised of the bones of the cranium and face.
    • Supported by cervical vertebrae.
    • Cranial Bones:
    • Frontal
    • Parietal
    • Occipital
    • Temporal
    • Sutures: Where adjacent cranial bones mesh:
    • Coronal
    • Sagittal
    • Lambdoid
    • Facial Bones: A total of 14 facial bones also articulate at sutures.
    • Facial Muscles:
    • Responsible for forming facial expressions.
    • Mediated by cranial nerve VII (the facial nerve).
    • Salivary Glands Accessible to Examination on the Face:
    • Parotid glands: Located in cheeks over the mandible, anterior to and below the ear; the largest of salivary glands, typically not palpable.
    • Submandibular glands: Beneath the mandible at the angle of jaw.
    • Sublingual glands: Located in the floor of the mouth.
    • Temporal Artery:
    • Lies superior to the temporalis muscle.
    • Pulsation is palpable anterior to the ear.

STRUCTURE: HEAD

  • Cranial and Facial Bone Identification:
    • List of bones:
    • Coronal suture
    • Frontal bone
    • Sagittal suture
    • Parietal bone
    • Nasal bone
    • Lacrimal bone
    • Maxilla
    • Mandible
    • Lambdoid suture
    • Occipital bone
    • Temporal bone
    • Sphenoid bone
    • Zygomatic bone
    • External acoustic meatus
    • Mastoid process
    • Temporomandibular Joint:
    • Essential for movement of the jaw.
    • Cervical Vertebrae:
    • C1 (Atlas)
    • C2 (Axis)
    • C7 (Vertebral prominens)

STRUCTURE AND FUNCTION: NECK

  • Neck Delimitation:
    • Defined by the base of the skull and the inferior border of the mandible above, extending to the manubrium sterni, clavicle, first rib, and first thoracic vertebra below.
    • Functions as a conduit for numerous structures:
    • Vessels
    • Muscles
    • Nerves
    • Lymphatics
    • Viscera of respiratory and digestive systems.
  • Major Neck Vessels:
    • Internal Carotid Artery:
    • Branches off common carotid and runs inward and upward to supply the brain.
    • External Carotid Artery:
    • Supplies the face, salivary glands, and superficial temporal area.
  • Major Neck Muscles:
    • Sternomastoid and Trapezius:
    • Innervated by cranial nerve XI.
    • Functions of the Sternomastoid include:
      • Head rotation and flexion.
      • Divides each side of the neck into two triangles: anterior and posterior triangles.
    • Trapezius Muscles:
      • Responsible for moving shoulders and extending and turning head.

THYROID GLAND

  • Definition:
    • Endocrine gland located in the neck, straddling the trachea.
  • Function:
    • Synthesizes and secretes:
    • Thyroxine (T4)
    • Triiodothyronine (T3)
    • Both hormones stimulate the rate of cellular metabolism.
  • Anatomy:
    • Consists of two lobes connected in the middle by a thin isthmus and above by the cricoid cartilage or upper tracheal ring.
  • Thyroid Cartilage:
    • Notable for its small palpable notch in the upper edge, typically referred to as the “Adam's apple” in males.

LYMPHATIC SYSTEM

  • Overview:
    • A major part of the immune system that detects and eliminates foreign substances from the body.
    • Rich supply of lymph nodes, primarily found in head and neck.
  • Function of Lymphatic Drainage:
    • Facilitates the prevention of potentially harmful substances from entering the circulation.
    • Important to be familiar with the drainage patterns of lymph nodes.

STRUCTURE AND FUNCTION: LYMPH NODES

  • Locations:
    • Preauricular: In front of the ear.
    • Posterior Auricular (Mastoid): Superficial to the mastoid process.
    • Occipital: At the base of the skull.
    • Submental: Midline, behind the tip of the mandible.
    • Submandibular: Halfway between angle and tip of the mandible.
    • Jugulodigastric: Under the angle of the mandible.
    • Superficial Cervical: Overlying the sternomastoid muscle.
    • Deep Cervical: Deep under the sternomastoid muscle.
    • Posterior Cervical: In the posterior triangle along the edge of the trapezius muscle.
    • Supraclavicular: Just above and behind clavicle, at the sternomastoid muscle.

INFANTS & CHILDREN

  • Neonatal Skull Structure:
    • Bones are separated by sutures and fontanels, allowing for brain growth during the first year.
    • Fontanels gradually ossify.
  • Closure of Fontanels:
    • Triangle-shaped posterior fontanel closes by 1 to 2 months.
    • Diamond-shaped anterior fontanel closes between 9 months and 2 years.
  • Head Growth Dynamics:
    • During the fetal period, head growth predominates, greater than chest circumference at birth, reaching 90% of eventual size by age 6.
    • During infancy, trunk growth predominates.
  • Growth Characteristics:
    • Facial bones grow at different rates; jaw size and nasal bridge characteristics vary in toddlers.
  • Lymphoid Tissue:
    • Well-developed at birth, growing to adult size by age 6.
  • Adolescence Changes:
    • Appearance of facial hair in boys, voice deepening with noticeable enlargement of thyroid cartilage.

PREGNANCY & AGING ADULT

  • Pregnant Female:
    • Thyroid gland enlarges slightly due to hyperplasia and increased vascularity during pregnancy.
  • Aging Adult:
    • Facial bones and orbits appear more prominent.
    • Skin undergoes sagging due to decreased elasticity, subcutaneous fat, and moisture.
    • Loss of teeth can result in a smaller lower face.

SUBJECTIVE DATA: HEALTH HISTORY

  • Key Health Questions:
    • Headache
    • Head injury
    • Dizziness
    • Neck pain, limitation of motion
    • Lumps or swelling
    • History of head or neck surgery
      -For infants and children:
    • Inquiry about maternal substance use, delivery type, growth pattern timeliness.
  • For aging adults:
    • Patient-centered care focusing on dizziness and neck pain impact on daily activities.

PHYSICAL EXAMINATION: SKULL & FACE

  • Skull Assessment:
    • Size and shape; normocephalic: round and symmetric.
    • Assessed by placing fingers in person’s hair and palpating scalp.
    • Normal protrusions from cranial bones include forehead, lateral edges of parietal bones, occipital bone, mastoid process.
  • Facial Inspection:
    • Structures should always exhibit symmetry.
    • Facial expression should match reported mood or behavior.
    • Look for abnormal features such as coarse facial characteristics, exophthalmos, or pigmentation changes.
    • Note presence of involuntary facial movements such as muscle tics.

PHYSICAL EXAMINATION: NECK

  • Neck Symmetry and Position:
    • Head should be centered in midline; accessory neck muscles symmetric.
    • Head must be held erect and still.
  • Range of Motion:
    • Evaluate if any limitations exist.
    • Check muscle strength.
  • Gland Assessment:
    • Inspect for enlargement and pulsations.
  • Lymph Node Palpation:
    • Note location, size, shape, delimitation, mobility, consistency, and tenderness of nodes.
  • Trachea Positioning:
    • Should be midline; palpate for tracheal shift.
    • Note any deviations.
  • Thyroid Gland Examination:
    • Difficult to palpate; check for enlargement, consistency, symmetry, and nodules.
    • Use posterior and anterior approaches for best examination.
    • Auscultate for bruit if the gland is enlarged.

EXAMINING LYMPH NODES

  • Palpation Technique:
    • Use a gentle circular motion of finger pads to palpate lymph nodes.
    • Begin with preauricular nodes, moving through 10 groups of lymph nodes systematically.
    • Maintain consistency in examination sequence to avoid missing small nodes.

PHYSICAL EXAMINATION: INFANTS AND CHILDREN

  • Skull Measurement:
    • Infant head size should be measured at each visit until age 2 years and annually until age 6 years.
  • Assessing Head Control:
    • By 2 weeks, infants can turn their heads side to side; check for variations due to maternal factors.
  • Common Variations:
    • Caput succedaneum: Edematous swelling across suture lines, self-limiting.
    • Cephalohematoma: Subperiosteal hemorrhage, well-defined, reabsorbed in weeks.
    • Molding: Overriding of cranial bones during delivery, resolves within days or a week.
    • Positional molding (positional plagiocephaly): Flattening caused by sleep position.
  • Fontanels: Must be observed for size and closure.
  • Neck Length: Infants have short necks, which lengthens in the first few years.
  • Lymph Node Palpability:
    • In infants, cervical lymph nodes are typically non-palpable; children’s nodes are usually palpable.
    • Nodes less than 3 mm are normal; increased incidence of illness-related adenopathy is expected in children.

PHYSICAL EXAMINATION: PREGNANT AND AGED ADULTS

  • Pregnancy Observations:
    • May witness chloasma (blotchy, hyperpigmented area on face).
    • Thyroid gland may be palpable due to tissue hyperplasia.
  • Aging Adult Observations:
    • Temporal arteries may become twisted and prominent; benign rhythmic tremor may occur.
    • Loss of teeth can result in a sunken mouth appearance.
    • Neck may exhibit increased concave curvature due to kyphosis; exercise caution with ROM assessments to reduce dizziness risk.

ABNORMAL FINDINGS: HEADACHES

  • Primary Headaches:
    • Defined through patient history; no abnormalities on exam or lab results noted.
  • Types of Headaches:
    • Tension
    • Migraine
    • Cluster
  • Factors to Review:
    • Definition, location, character, duration, severity, triggers, associated symptoms, and treatment efforts.

ABNORMAL FINDINGS: PEDIATRICS

  • Conditions:
    • Hydrocephalus: Obstruction of cerebrospinal fluid drainage leading to increased intracranial pressure and head enlargement.
    • Down Syndrome: Characterized by facial abnormalities including:
    • Upslanting eyes, flat nasal bridge, protruding tongue.
    • Broad neck and small hands with a single palmar crease.
    • Plagiocephaly: Positional or deformational head shape alteration.
    • Craniosynostosis: Premature closure of cranial sutures leading to abnormal shapes.
    • Atopic (allergic) facies: Effects of chronic allergies yielding various facial features such as exhausted look and central facial pallor.
    • Fetal Alcohol Spectrum Disorders (FASD): Features include narrow palpebral fissures and midfacial hypoplasia.

ABNORMAL FINDINGS: SWELLINGS OF HEAD AND NECK

  • Congenital Torticollis: Hematoma in one sternomastoid leading to head tilt.
  • Simple Diffuse Goiter (SDG): Chronic thyroid enlargement due to iodine deficiency.
  • Thyroid—Multinodular Goiter (MNG): Presence of multiple nodules indicative of inflammation rather than carcinoma, with suspicion for rapid growth or firmness.
  • Pilar Cyst (Wen): Benign scalp swelling.
  • Parotid Gland Enlargement: Can rapidly enlarge due to mumps, duct blockage, or tumor.

ABNORMAL FINDINGS: THYROID DISORDERS

  • Graves Disease:
    • Physical presentations include goiter and exophthalmos (abnormal protrusion of the eyeball).
    • Hypothyroidism symptoms: Puffy, edematous face, and coarse facial features.

ABNORMAL FACIAL APPEARANCES ASSOCIATED WITH CHRONIC ILLNESSES

  • Acromegaly: Enlarged head and facial structures due to excess growth hormone.
  • Cushing Syndrome: Characteristic moonlike face and red cheeks.
  • Bell Palsy: Unilateral facial paralysis due to a lower motor neuron lesion.
  • Stroke or Brain Attack: Upper motor neuron lesion causing lower facial muscle paralysis.
  • Parkinson Syndrome: Presents with a classic mask-like appearance and drooling.
  • Cachectic Appearance: Associated with chronic wasting conditions leading to a defeated expression and sunken features.

SUMMARY CHECKLIST: HEAD, FACE, AND NECK, INCLUDING REGIONAL LYMPHATICS EXAMINATION

  • Inspection & Palpation:
    • Inspect skin for general size and contour; note deformities.
    • Palpate temporal artery and temporomandibular joint (TMJ).
    • Inspect and palpate the face for symmetry of movement (Cranial Nerve VII) and any abnormal movements.
    • Assess neck through active ROM, checking for gland size and trachea position.
    • Auscultate thyroid for bruit if enlarged.