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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