Download Chapter 10 Head and Neck Together the head and neck provide the

Chapter 10
Head and Neck
Together the head and neck provide the bony housing and protective cover for the brain,
including the organs that provide senses of:
Vision
Hearing
Smell
Taste
Physical Examination Preview
Head
Observe head position:
Tilted
Tremor
Inspect skull and scalp for the following:
Size
Shape (molding)
Symmetry
Lesions
Trauma
Head (Cont.)
Inspect facial features, including the following:
Symmetry
Shape
Unusual features
Tics
Characteristic facies
Pallor or pigmentation variations
Head (Cont.)
Palpate head and scalp, noting the following:
Symmetry
Tenderness (particularly over areas of frontal and maxillary sinuses)
Scalp movement
Sutures/ fontanels
Hair texture, color, and distribution
Head (Cont.)
When appropriate auscultate the temporal arteries and palpate, noting the following:
Thickening
Hardness
Tenderness
Inspect and palpate the salivary glands.
Transilluminate the skull of infants with rapidly increasing head circumference.
Neck
Inspect the neck for the following:
Symmetry
Alignment of trachea
Fullness
Masses, webbing, and skinfolds
Palpate the neck, noting the following:
Tracheal position
Tracheal tug
Movement of hyoid bone and cartilages with swallowing
Lymph nodes
Neck (Cont.)
Palpate the thyroid gland for the following:
Size
Shape
Configuration
Consistency
Tenderness
Nodules
If gland is enlarged, auscultate for bruits.
Evaluate range of motion of the neck.
Anatomy and Physiology
Skull
Skull is composed of seven (fused) bones
Frontal: two (2 bones)
Parietal: two (2 bones)
Temporal: two (2 bones)
Occipital: one (1 bone)
Facial cavities
Eyes
Nose
Mouth
Skull (Cont.)
Skull (Cont.)
Face bones
Frontal (fused)
Nasal
Zygomatic
Ethmoid
Lacrimal
Sphenoid
Maxillary
Mandible (movable)
Skull (Cont.)
Major landmarks of the face
Palpebral fissures
Nasolabial folds
Facial muscles innervated by cranial nerves V and VII
Temporal artery: major accessible artery of the face
Salivary Glands
Produce saliva
To moisten mouth
To prevent caries
To initiate digestion of carbohydrates
Three paired glands
Parotid gland: anterior to ear, above mandible
Submandibular gland: medial to mandible at
angle of jaw
Sublingual gland: anterior in floor of mouth
Neck
Provides support and movement
Structure of neck formed by:
Cervical vertebrae
Ligaments
Sternocleidomastoid muscles
Trapezius muscles
Neck (Cont.)
Posterior triangle formed by:
Trapezius muscle
Sternocleidomastoid muscle
Clavicle
Anterior triangle formed by:
Medial border of sternocleidomastoid muscle
Mandible
Neck (Cont.)
The neck contains:
Trachea
Esophagus
Internal and external jugular veins
Common carotid
Internal and external carotid arteries
Thyroid
Thyroid
Thyroid is the largest endocrine gland in body.
Produces two hormones
T3: thyroxine
T4: triiodothyronine
Located on each side of the trachea and joined by the isthmus below the cricoid cartilage
Infants
Cranial bones are soft and separated by sutures.
Sutures and fontanels permit skull expansion to accommodate brain growth.
Sutures ossify (age 6 to18 years).
Fontanels close (age 2 months to 2 years).
Infants (Cont.)
Infants (Cont.)
Skull molding from birth through vaginal canal
Skull bones shift and overlap
Normal shape and size resumed within days
Children and Adolescents
Subtle changes in facial appearance throughout childhood
Male adolescent facial changes
Nose and thyroid cartilage enlarge.
Facial hair appears.
Pregnant Women
Changes in thyroid gland and hormones
Pregnancy is an euthyroid state.
Early and sustained increase seen in the renal clearance of iodine.
Thyroid compensates by enlarging to produce sufficient thyroid hormones.
Pregnant Women (Cont.)
Changes in thyroid gland and hormones (Cont.)
As long as adequate iodine intake is maintained (200 mcg/day), the size of the thyroid will
not change by physical examination.
Slight enlargement may be detectible by ultrasound.
Older Adults
The rate of T4 production and degradation gradually decreases with aging.
Thyroid gland becomes more fibrotic.
Review of Related History
History of Present Illness
Head injury
Independent observer’s description of event
State of consciousness after injury
Predisposing factors
Associated symptoms
Medications
History of Present Illness (Cont.)
Headache
Onset
Duration
Location
Character
Severity
Visual prodrome
Pattern
Change in LOC
Associated symptoms
Precipitating factors
Treatment efforts
Medications
History of Present Illness (Cont.)
Stiff neck
Neck injury or strain, head injury, swelling
Fever, bacterial, or viral illness
Character
Predisposing factors
Efforts to treat
History of Present Illness (Cont.)
Thyroid problem
Changed temperature preference
Swelling of neck
Change in texture of hair, skin, or nails
Change in emotional stability
Increased prominence of eyes (exophthalmos)
Tachycardia, palpitations
Change in menstrual flow
Change in bowel habits
Medications: thyroid preparations
Past Medical History
Head trauma, subdural hematoma, recent lumbar puncture
Radiation treatment around head and neck
Headaches: migraine, vascular
Surgery for tumor, goiter
Seizure disorder
Thyroid dysfunction
Family History
Headaches: type, character
Thyroid dysfunction
Personal and Social History
Employment risks
Stress
Injury risks
Nutrition
Use of alcohol/street/recreational drugs
Sports played, weight training, new activities, use of protective padding and helmet, if necessary
Infants
Prenatal history
Birth history
Unusual head shape
Head control
Acute illness
Congenital anomalies
Neonatal screening for hypothyroidism
Pregnant Women
Gestation or postpartum duration
Presence of preexisting disease
History of pregnancy-induced hypertension
Use of alcohol/street drugs
Older Adults
Dizziness with head or neck movement
Weakness or impaired balance increasing risk of falling and head injury
Examination and Findings
Head and Face
Techniques
Inspection
Palpation
Percussion
Auscultation
Head and Face (Cont.)
Inspection
Facial features
Facial asymmetry
Tics
Spasms
Head position and shape
Skull size and shape
Scalp
Hair pattern
Head and Face (Cont.)
Palpation
Skull symmetric and smooth
Scalp movement
Hair texture
Temporal arteries
Temporomandibular joint (TMJ) space
Salivary glands
Head and Face (Cont.)
Percussion
Not routinely performed on head and face
One exception is when evaluating for hypocalcemia
Percussion on the masseter muscle may produce a hyperactive masseteric
reflex, Chvostek sign.
Auscultation
Not routinely performed on skull
Bruit
Cerebral aneurysm
Temporal arteritis
Neck
Inspection
Muscle symmetry
Alignment of trachea
Landmarks of triangles
Fullness at base of neck
Masses
Webbing
Unusual shortness
Asymmetry
Carotid artery prominence
Jugular vein distention
Range of motion (ROM)
Neck (Cont.)
Palpation
Tracheal alignment
Smoothness and tenderness
Hyoid bone
Thyroid cartilage
Cricoid cartilage
Tracheal tugging
Suggests the presence of an aortic aneurysm
Lymph nodes
Thyroid Gland
Inspection
Symmetry
Swallowing symmetry
Palpation
Size and shape
Configuration and consistency
Tenderness
Nodules
Thyroid Gland (Cont.)
Auscultation
If thyroid gland is enlarged, auscultate for vascular sounds.
In a hypermetabolic state, the blood supply is dramatically increased and a vascular bruit,
a soft rushing sound, may be heard.
Infants
Inspection
Head circumference
Head symmetry of shape
Fontanels
Scalp scaling or crusting, dilated scalp veins
Hair and hairline
Caput succedaneum or cephalhematoma
Head control, position, movement
Infants (Cont.)
Inspection (continued)
Facial features
Facial symmetry
Neck symmetry, size, and shape
Infants (Cont.)
Palpation
Suture lines and fontanels
Craniotabes: softening of the outer table of the skull
Neck muscle tone and masses
Trachea
Thyroid goiter
Infants (Cont.)
Transillumination
Transilluminate the skull of infants who have suspected intracranial lesions or a rapidly
increasing head circumference
Performed less often today because of availability of computed tomography (CT) scan
Children
Percussion of skull with one finger to detect Macewen sign
Stronger resonant sound when either hydrocephalus or a brain abscess is present
Bruits common in children up to 5 years of age
Thyroid may or may not be palpable
Pregnant Women
Inspect for chloasma (mask of pregnancy).
Palpate for hypertrophy of thyroid.
Auscultate for thyroid bruit.
Older Adults
Facies vary with nutritional status
Sunken eyes
Eyelids loose and wrinkled
Evaluate range of motion (ROM) of neck slowly and cautiously.
Pain or crepitus
Jerkiness or limited movement
Palpate thyroid for nodules or irregularities.
Thyroid more fibrotic as individual ages
Feels more nodular or irregular on palpation
Abnormalities
Head
Headaches
Classic migraine
Common migraine
Cluster
Hypertensive
Muscular tension
Temporal arteritis
Head (Cont.)
Salivary gland tumor
Tumor in any of the salivary glands, but most commonly in the parotid
Neck
Thyroglossal duct cyst
Palpable cystic mass in the neck
Neck (Cont.)
Branchial cleft cyst
Congenital lesion formed by incomplete involution of branchial cleft
Torticollis (wry neck)
Birth trauma, tumors, trauma, cranial nerve palsy, muscle spasms, infection, drug
ingestion
Thyroid
Hypothyroidism
Underactive thyroid
Hyperthyroidism
Overactive thyroid
Myxedema
Skin and tissue disorder usually due to severe prolonged hypothyroidism
Thyroid (Cont.)
Graves disease
Autoimmune, antibodies to thyroid-stimulating hormone receptor, leading to overactive
thyroid
Hashimoto disease
Autoimmune antibodies against thyroid gland, often causing hypothyroidism
Infants
Encephalocele
Neural tube defect with protrusions of brain and membranes that cover it through
openings in the skull
Microcephaly
Circumference of head is smaller than normal because brain has not developed properly
or has stopped growing
Infants (Cont.)
Craniosynostosis
Premature closure of one or more cranial sutures before brain growth complete
Leads to misshapen skull
Question 1
Facial muscles are innervated by which of the following cranial nerves?
A. CN IV and V
B. CN V and VI
C. CN V and VII
D. CN VI and VII
Question 2
Closure of the anterior skull fontanel should occur by _____ months.
A. 6
B. 12
C. 18
D. 24
Question 3
The thyroid produces which two hormones?
A. Thyroid-stimulating hormone and thyroxine
B. Thyroid-stimulating hormone and triiodothyronine
C. Thyroxine and triiodothyronine
D. Thyroid autoantibodies and thyroid stimulating hormone
Question 4
Which of the following is a chronic autoimmune disorder?
A. Microcephaly
B. Hashimoto disease
C. Salivary gland tumor
D. Down syndrome
Question 5
Mrs. Wagner is a 45-year-old patient. You are examining her thyroid and note a course and gritty
sensation this is indicative of:
A. Cancer
B. Nodules
C. Goiter
D. Inflammatory process