Head and Neck

Head is comprised of bones and cavities that give face structure and function to protect the brain, eyes, ear, nose, and mouth. Cranial bones of the infant skull are soft and structures differently to allow for expansion of the skull and brain growth.

• Skull is comprised of 7 fused bones and 3 facial cavities that house the eyes, nose, and mouth.

• Face is comprised of several bones that create facial structure. Innervated by cranial nerves V and VII. Blood supply is provided by temporal artery

  • Skull Bones: Two frontal bones, two parietal bones, two temporal bones, and 1 occipital bone

  • Face Bones:

    • Frontal (fused),

    • nasal,

    • zygomatic (forms the prominence of the cheek, lower part of the orbit of the eye, and parts of the temporal and infratemporal fossae),

    • ethmoid (spongy bone at base of cranium, forms the roof and most of the walls of the superior part of the nasal cavity),

    • lacrimal (one of the smallest and most fragile bones in the face, anterior part of medial wall of orbit, unites with maxilla to form groove for lacrimal sac)

    • sphenoid (wedge shaped)

    • maxillary

    • mandible (moveable)

  • Palpebral fissure and nasolabial folds

• Infant Skull: Soft and separated by sutures (sagittal, coronal, and lambdoid). Ossification of skull bones occurs after completion of brain growth (around 6 years of age). Has openings called fontanels (mastoid, posterior, sphenoid, and anterior). Both allow expansion of skill during brain growth. Posterior fontanel close by 2 months, anterior fontanel closes between 12 and 15 months.

Neck is formed by the vertebrae, ligaments, and muscle providing support for the head and allowing for movement. Also includes the sternocleidomastoid and trapezius muscles.

• Beginning with clavicle and sternum, neck contains the trachea, esophagus, internal and external jugular veins, common carotid, internal and external carotid arteries, and thyroid glands.

History of Present Illness: Head and Neck

• Onset, duration, descriptions of events (if injury), state of consciousness after injury (if injury), location

• Associated symptoms:

  • Photophobia, phonophobia, nausea, vomiting, diarrhea, insomnia, tinnitus, headache, neck pain, tenderness, breathing pattern change, blurred or double vision, ear/nose drainage, impaired movements of extremities, fever, swelling, voice distortion, hearing loss, dysphagia, irritability, exophthalmos

• Aggravating, alleviating factors, efforts to treat, medications

• Character, severity (patient self-reporting), predisposing factors

  • Seizures, hypoglycemia, poor vision, syncope, dizziness, fever, fatigue, stress, food, fasting, alcohol, allergies, menstruation, injury, strain, traumatic brain injury, work position.

Medical Surgical History: Head and Neck

• Head/neck trauma, subdural hematoma, lumbar puncture, radiation therapy around head/neck, chronic headaches, surgery of tumors, seizure disorder, thyroid defunctions.

Family History: Head and Neck

• Headaches, thyroid dysfunction

Personal/Social History: Head and Neck

• Environmental hazards, nutrition, Tabacco/alcohol use, drug use, physical activity, protective devices, stress level.

Assessment of the Head: Inspect and palpate entire head, observe head position, facial features, skull, and scalp hair.

Assessment of Neck: Inspection and Palpation

Assessment of the Neck

A thorough inspection of the patient’s neck involves both inspection and palpation.

Assessment of Infant Head and Neck

Assessment of Newborn Skull

• Palpate suture lines and fontanels. Fontanels should be soft and flat

• Palpate skull for birth trauma

  • Caput Succedaneum: Edema over presenting part of the head

  • Cephalohematoma: Collection of blood under skin bound by suture lines

• Percuss skull for Macewen sign near junction of frontal temporal and parietal bones

  • If hydrocephalus or brain abscess if present, percussion will result in stronger resonant sound

• If infant has rapidly increasing head circumference suggestive of intracranial lesions, transillumination of the infant’s skull may be necessary. This is performed by placing transilluminator firmly against midline frontal region and inching light over entire heed. Note symmetry.

• Temporal artery should be auscultated for presence of bruits

Assessment of Infant Neck

• Inspection: Symmetry, size, shape, head control.

  • Neck may not be visible in supine position.

• Palpation

  • Sternocleidomastoid muscle for tone and masses

  • Trachea

  • Thyroid - it’s difficult to find in infants unless enlarged

  • Clavicles for crunch indicating fracture during childbirth process.

Normal Assessment Findings: Head

Normal Assessment Findings: Neck

Abnormal Assessment Findings: Head

• Inspection of the Head and Face

  • Head tilted

  • Horizontal jerking/bobbing

  • Tics/nodding

  • Edema, puffiness

  • Unexpected alopecia

  • Coarsened features (e.g., enlarged forehead, nose, prominent veins)

  • Prominent eyes

  • Hirsutism

  • Lack of expression

  • Excessive perspiration

  • Pallor

  • Pigmentation variations

  • Facial nerve weakness/paralysis

  • Scalp lesions, scabs (crusts), parasites, nits, scales, tenderness

  • Random areas of baldness

  • Ptosis

  • Nasal malalignment

  • In infants: any tenderness, depression, sunken area, swelling, bulging, or depression of the fontanel

• Palpation of the Head and Face

  • Indentations or depressions

  • Elevations

  • Hair: splitting, cracked ends, coarse, dry, brittle or fine/silky

  • Thickening, hardness, tenderness, thrill of temporal arteries

  • Salivary glands symmetrical, enlargement or tenderness.

  • A bruit auscultated over the temporal artery is an abnormal finding.

Abnormal Assessment Findings: Neck

• Inspection of the Neck

  • Asymmetry

  • Torticollis (twisting of the head toward the sternocleidomastoid muscle)

  • Excessive posterior skinfolds

  • Unusually short

  • Jugular vein distention

  • Thyroglossal duct cyst (movable mass in the neck)

  • Branchial cleft cyst (mass along anteromedial border of sternocleidomastoid muscle)

  • Prominence of carotid arteries

  • Webbing

  • Edema

  • Masses

  • Pain, or limited movement with range of motion

  • Nuchal Rigidity

• Palpation of the neck

  • Trachea deviated to the right or left

  • Tenderness

  • Tracheal tug synchronous with pulse

  • Lymph nodes

    • Enlarged

    • Matted

    • Tender

    • Fixed

    • Warm

  • Thyroid gland

    • Asymmetry

    • Enlargement

    • Visible

    • Tender

    • Coarse tissue

    • Gritty sensation

  • Thrill palpated over carotid arteries

  • The nurse would consider an auscultated bruit over the carotid arteries an abnormal finding.

Document History and Present Illness: Head and Neck

Documentation of Medical, Surgical History

• Head trauma

• Subdural hematoma

• Recent lumbar puncture

• Radiation treatment in head/neck area

• Surgery for tumor, goiter (enlarged thyroid gland)

• Seizure disorder

• Thyroid dysfunction

Documentation of Family History:

• Headaches (type, character, similarity to patient’s symptoms)

• Thyroid dysfunction

• Graves disease

Personal/Social History

• Employment risk: exposure to fumes, chemicals, particulates

• Stress and coping mechanisms

• Injury risk

• Use of alcohol, recreational drugs

• Sports played, weight training, new activities, use of protective padding, helmet

Documentation of Objective Findings: Head and Neck

• Important to note findings from other body systems such as changes in weight, bowel habits, and energy level, as they may indicate possible thyroid disease

• Also document

  Size of the thyroid Neck swelling Goiter Nodules Fine hair Brittle nails Proptosis Abnormal gait

  Coarse, thick skin Swollen lips Puffiness around eyes Slow speech Thin, brittle hair with bald patches Exophthalmos Bruit over thyroid (may suggest thyroid disease) Papilledema Nystagmus

Key Points

Head

• Head contains the skull that protects the brain and special sense organs.

• Cranial bones unite at immovable joints called sutures. 14 facial bones articulate at sutures. Mandible (part of the 14 facial bones) does not articulate at a suture but instead it has a movable temporomandibular joint anterior to each ear.

• Temporal. artery lies superior to temporalis muscle. Pulsations palpable anterior to ear.

• Sublingual and submandibular salivary glands are accessible to examination.

• Parotid glands are in cheeks over mandible. Not normally palpable.

Neck

• Delimited by the skull and mandible above manubrium sterni, clavicle, first rib, and first thoracic vertebra below.

• Nerves, lymphatics, and respiratory and digestive systems pass through neck.

• Carotid artery and internal jugular vein lie beneath sternomastoid muscle

• External jugular vein runs diagonally across sternomastoid muscle

• Major neck muscles are sternomastoid and trapezius. Innervated by cranial nerve XI

• Sternomastoid muscle divides each side of the neck into two triangles. Head rotation and flexion.

• Anterior triangle extends to mandible above and midline of body medially.

• Posterior triangle lies behind sternomastoid muscle and in front of trapezius.

• Thyroid gland is important endocrine glands. Straddles trachea in middle of neck. Thyroid cartilage lies above thyroid isthmus.

Lymph Nodes in Head and Neck

• Preauricular nodes: In front of ear

• Posterior Auricular Nodes: Superficial to mastoid process.

• Occipital Nodes: Falt at base of skull

• Submental Nodes: Midline structures behind tip of mandible

• Submandibular Nodes: Halfway between angle of mandible and its tip

• Jugulodigastric Nodes (Tonsillar Nodes): Under the angle of the mandible

• Superficial Cervical odes: Overlay the sternomastoid muscle

• Deep Cervical Nodes: Deep under the sternomastoid muscle

• Posterior Cervical Nodes: In posterior triangle along edge of trapezius muscle

• Supraclavicular Nodes: Above and behind clavicle at sternomastoid muscle

Developmental Changes:

• Birth: Head is larger than chest circumference. Skull bones separated by futures and fontanels. Lymphoid tissue is developed at birth and grows to adult size by age 6. At 12-11, lymph tissue exceeds adult size and slowing atrophies.

• Pregnancy: Thyroid gland enlarges as result of hyperplasia of the tissue and increased vascularity

• Aging Adults: Facial bones and orbits appear more prominent. Facial skin sags due to decreased elastic, moisture, and subcutaneous fat.

Subjective Data (Ask questions based on these topics)

• Headaches and head injury

• Dizziness

• Neck pain, limited ROM, numbness, tingling

• Lumps or swelling, difficulty swallowing

• History of smoking

• Did mother use alcohol or street drugs, had a vaginal or cesarean birth, was baby’s growth on schedule.

• Dizziness, ability to drive, ability to sleep (in aging adults)

Objective Data

• Inspect and palpate the skull

  • Size and shape. Deformities, lumps, tenderness

  • Palpate temporal artery and temporomandibular joint

• Inspect face

  • Facial expression, symmetry of movement (functioning of cranial nerve VII)

  • Involuntary movement, edema, lesions

• Inspect and palpate the neck

  • Symmetry of head position, ROM

  • Muscle strength, status of cranial nerve XI using shrug test

  • Palpate for enlargement of lymph nodes, salivary glands, and thyroid gland

  • Palpate position of trachea (normally midline)

  • If there are lymph node abnormalities, explore area proximal to affected node. If thyroid enlarged, auscultate for bruits

• Additional assessment based on developmental stage

  • Infant: measure head size, palpate fontanels, note tonic neck reflex

  • Pregnant Woman: Chloasma (Blotchy hyperpigmented area over cheeks and forehead and thyroid gland enlargement)

  • Aging Adult: Prominent temporal artery, kyphosis of spine, senile tremors.

Class Notes

Structure and Function

• Head

  • Cranial Bones: Frontal, partial, occipital, and temporal

  • Sutures: Immovable in adults, no fused together in infants (allow movement for birthing process and brain growth)

  • Facial Bones: 14

  • Facial Muscles: Controlled by cranial nerve 7. Expect symmetry

  • Salivary Glands

    • Parotid: the largest salivary gland, located near the ear, responsible for producing saliva that aids in digestion.

    • Submandibular: Under angle of jaw

    • Sublingual: Under tongue in floor of mouth. Can not palpate

• Neck

  • Neck Muscles:

    • Sternomastoid Muscle: A major muscle located in the neck that facilitates head rotation and flexion.

    • Trapezius Muscle: A large muscle extending from the back of the skull to the mid-back, responsible for moving, rotating, and stabilizing the shoulder girdle.

  • Anterior and posterior triangles

    • Anterior triangle: An anatomical region of the neck bounded by the midline of the neck, the mandible, and the sternocleidomastoid muscle, containing vital structures such as the carotid artery, internal jugular vein, and cranial nerves.

    • Posterior Triangle: An anatomical area of the neck located posterior to the sternocleidomastoid muscle and bounded by the trapezius muscle, the clavicle, and the sternocleidomastoid, which includes structures such as the brachial plexus and the external jugular vein.

  • Thyroid Gland: A butterfly-shaped endocrine gland located anterior to the trachea, responsible for regulating metabolism, growth, and development through the production of thyroid hormones, primarily thyroxine (T4) and triiodothyronine (T3). Base of neck.

  • Spinous Process is located on C7

• Lymph Nodes: Move lymph fluid and filer it before it brings it back into circulation. Not normally palpable but if we do feel them, they should be less than 1 cm in size, freely movable, soft, and non-tender. Use finger pads in rotating motion to palpate.

  • Preauricular: Infront of ear

  • Posterior Auricular (Mastoid): Behind ear

  • Occipital: Over occipital bones at base of skull

  • Submental: Under tip of jaw

  • Submandibular: Located beneath the jaw, between the mandible and the digastric muscles.

  • Jugulodigastric: Tonsil

  • Superficial Cervical: Onto of sternomastoid muscle

  • Deep Cervical: Underneath sternomastoid muscle. Pt tilt head to one side

  • Posterior Cervical: Along the posterior border of the sternocleidomastoid muscle. Posterior triangle

  • Supraclavicular: Just above clavicle. Pt raise shoulder to palpate.

Developmental Considerations

• Infants

  • Fontanels (Soft Spots). Expect them to be flat. Bulging could mean increased intercranial pressure. Sunken could be dehydration or fluid volume deficit.

    • Anterior: Closes in 9 months to 2 years

    • Posterior: Closes in 1-2 months of age

• Pregnant Woman:

  • Thyroid gland enlarges

• Aging Adults

  • Facial bones and orbits more prominent

  • Facial skin sags

  • Decrease subcutaneous fat

  • Decreased moisture in skin

  • Lower face may look smaller if teeth have been lost

Subjective Data

• Headache: Severe headaches in pt who normally doesn’t get headaches. “This is the worst headache I’ve ever experienced”

• Head injury: When did it occur, lost consciousness, Symptoms or problems after, sleeping problems, staying awake problems, confusion, memory problems

• Dizziness: Any vertigo

• Neck pain/Limited ROM:

• Lumps or Swelling: Any recent infections? Difficulty swallowing

• History of head or neck surgery:

Objective Data - The Physical Exam

• Inspect head and palpate the skull

  • Size and shape: Sound and symmetric is normocephalic

  • Temporal area: Palpate for tenderness and observe the contour, noting any abnormalities such as swelling or skin changes.

    • Temporal mandibular joint: Palpate and have pt open and close their mouth to assess for crepitus, range of motion, and any pain associated with movement. Crepitus present?

• Inspect the face:

  • Facial Structures: Facial expression, symmetry (eyebrows, eyes, nasal labial folds, mouth), edema, involuntary movement, skin (redness, edema, lesions, hypo or hyperpigmentation)

• Neck - Inspect and palpate

  • Symmetry, ROM, Lymph Nodes, Trachea, Thyroid gland (posterior, anterior, and auscultate for bruits if enlarged)

Abnormal Findings

Headaches

• Tension Headache, also called a stress headache. Musculoskeletal origin. 3x more common in women than men.

  • Usually both side of head across frontal, temporal, and occipital region of head. Feels like a band tightness, no throbbing.

  • Gradual onset and lasts 30 minutes to 7 days. Dull aching pain.

  • Usually in response to overwork or posture. Stress, anxiety, depression, poor posture, poor sleep can cause it.

  • Physical activity makes it worse.

  • Associated with fatigue, anxiety, and stress and sometimes photophobia or phonophobia.

  • Relievers: NSAIDs, antidepressants, muscle relaxants

  • Three types

    • Episodic infrequent is less than 1 day a month

    • Episodic frequent is less than 15 days a month

    • Chronic is more than 15 days a month for three months

• Migraine Headache of a trigeminal nerves or vascular origin. Moderate to severe intensity lasting 4-72 hours. 3x more common in women than men.

  • Three categories:

    • Migraine without aura

    • Migraine with aura

    • Chronic (more than 15 days out of the month for 3 months

  • Commonly one sided but can occur in both sides, especially in children and adolescents. Pain located behind eyes, temples, or forehead

  • Throbbing, pulsating pain, rapid onset that peals for 1-2 hours and lasts 4-72 hours. Moderate to severe pain

  • 4 stages

    • Prodrome: Hours to days before the migraine. Change in mood, behavior, and sensitivity to light, sound, smell, hunger, cravings, more fatigued, yawning, constipation or diarrhea.

    • Aura: 5-60 minutes. Visual changes like blind spots, wavy lines, and flashes of light. Tingling in arm or leg, vertigo. Speech and language change.

    • Migraine attack: 4-72 hours

    • Postdrome: 24-48 hours after. Fatigue and irritability.

  • Can cause hormonal fluctuations (premenstrual) as an aggravating symptom.

  • Aggravating triggers: alcohol, caffeine, cheese, chocolate, salty or processed foods, MSG, aspartame. Hunger, stress, sleep changes, sensory stimuli, weather changes, physical activity

  • Associated symptoms: Nausea, vomiting, photophobia, phonophobia. Person may look sick. Family history

  • Relieving factors: Lie down, darken room, eyeshade, NSAIDs, preventive meds, therapy, lifestyle changes

• Cluster Headache: Intermittent, excruciating unilateral. 3x more common in men. Typically starting in 20s to 40s

  • Located one side usually behind or around the eye or temple.

  • Continuous, sharp, burning, piercing, excruciating.

  • Abrupt onset that peaks in minutes and lasts for 15-180 min

  • Can occur multiple times a day in clusters lasting weeks. Very severe pain

  • Often occurring at night

  • Aggravating triggers: Alcohol, nitroglycerin, histamine organic compounds like paint or perfume.

  • Associated symptoms: Nasal congestion or runny nose, watery or reddened eye, eyelids dropping or edema, facial sweating. Feelings of agitation or restlessness, need to move, unable to lie down, may have migraine-like symptoms of nausea, vomiting, phonophobia and photophobia.

  • Relieving factors: Therapies, preventive meds

Pediatric Abnormalities

• Hydrocephalus: Obstruction of drainage of cerebral spinal fluid results in excessive accumulation. Increased intracranial pressure and enlargement of head.

  • Produces full fontanel, dilated scalp veins, frontal bossing, and downcast eyes.

  • Cranial bones are thin, sutures are separate, percussions yield a cracked pot sound.

• Plagiocephaly: A condition characterized by an asymmetrical distortion or flattening of the head, typically due to positional factors during infancy. This can occur when a baby spends too much time in one position, leading to cranial deformation. It can be classified into two types: positional plagiocephaly, which is often treatable with repositioning techniques, and congenital plagiocephaly, which may require more advanced medical intervention.

• Craniosynostosis: Premature closing of one or multiple cranial sutures. Malformed head and cosmetic deformity. Genetic mutations coding structural proteins or growth factor receptors. Severe deformities cannot contain the brain, eyes, and optic nerves inside cranial vault and needs surgery.

• Atopic (Allergic) Facies: A distinct facial appearance often seen in individuals with allergic conditions, characterized by features such as a dry, pale complexion, small dark circles under the eyes (allergic shiners), and a prominent nasal fold due to chronic nasal congestion.

• Allergic Salute and Crease: A classic sign of allergic rhinitis, where individuals rub their noses upward with the palm of their hand, leading to the development of a transverse crease on the nose. This gesture is often a response to itching or irritation caused by allergens, highlighting the chronic nature of their nasal symptoms.

• Fetal Alcohol Spectrum Disorders: A group of conditions resulting from exposure to alcohol in utero, leading to a range of developmental and birth defects, including distinct facial features, growth deficiencies, and central nervous system dysfunction.

• Down Syndrome: Most common chromosomal condition (trisomy 21). Individuals with Down Syndrome may present with characteristic facial features such as a flat facial profile, slanted eyes, and a protruding tongue, along with potential congenital heart defects and varying degrees of intellectual disability.

Swellings on Head or Neck

• Congenital Torticollis: Hematoma in one sternomastoid muscle results in head tilt to one side and limits neck ROM. Feel firm, discrete, nontender mass in mid muscle on involved side. Requires treatment or muscle can become fibrotic and permanently shorted with permeant limitation in ROM.

• Simple Diffuse Goiter (SDG): Chronic enlargement of thyroid glands. Common in wide regions of the world especially in mt regions where soil is low in iodine. (Iodine is essential element in formation of thyroid hormones).

• Thyroid Multinodular Goiter: Multiple nodules usually indicate inflammation rather than neoplasm.

• Single Nodule Goiter: Thyroid nodules are palpable. Suspect any painless, rapid growing nodule. Cancerous nodules are usually hard and fixed to surrounding structure. Increased risk in females and those with family history or exposure to radiation.

• Piler Cyst: Smooth, firm, fluctuant swelling on scalp that contains sebum and keratin. Tense pressure of contents causes overlying skin to be shiny and taunts. Well circumscribed, mobile, and benign growth.

• Parotic Gland Enlargement: Rapid, painful inflammation of parotid occurs with mumps. Caused by blockage of duct by calculus, abscess, or tumor, acute viral or bacterial infections, autoimmune diseases, and neoplastic diseases

Thyroid Hormone Disorders

• Graves’ Disease (Hyperthyroidism): Autoimmune disorder with increase production of thyroid hormones. Causes increased metabolic rate. Manifested by goiter, eyelid retraction, bulging eyes (exophthalmos). Symptoms: nervousness, fatigue, weight loss, muscle cramps, heat intolerance, poor sleep, irritability, anxiety, depression, and diarrhea. Signs: Tachycardia, SOA, diaphoresis, muscle tremors, thin silky hair, moist skin, infrequent blinking, staring appearance, and hyperreflexia.

• Myxedema (Hypothyroidism): Deficiency of thyroid hormone. Reduces metabolic rate, can cause nonpitting edema or myxedema. Usually caused by Hashimoto thyroiditis. Symptoms: fatigue, weight gain, constipation, difficulty thinking, cold intolerance. Signs: Puffy edematous face, cool dry skin and hair, slowed reflexes, slower speech

Abnormal Facies with Chronic Illness

• Acromegaly: Excessive secretion of growth hormone from pituitary gland after puberty creates enlarged skull and thickened cranial bones. Elongated head, massive face overgrowth of nose and lower jaw, heavy eyebrow ridge, coarse facial features

• Cushing Syndrome: Excessive secretion of ACTH and chronic steroid use. Person develops rounded face, prominent jowls, red cheeks, hirsutism on upper lip, lower cheeks, and chin, acneiform rash on chest.

• Bell Pasley: Lower motor neuron lesion producing rapid onset of cranial nerve VII paralysis of facial muscles, almost always unilateral. May be reactive of herpes simplex.

• Stroke: Upper motor neuron lesion. Acute neurologic deficit caused by blood clot of cerebral vessel.

• Parkinson Syndrome: Deficiency of neurotransmitter dopamine and degeneration of substantia nigra of basal ganglia in brain. Immobility produces face that is flat and expressionless. Elevated eyebrows, staring gaze, oily skin, drooling.

• Cachexia: Wasting syndrome associated with complex disease processes Signs include severe weight loss, loss of muscle, sunken eyes, hollow cheeks, fatigue, muscle weakness, and anorexia.