Head and Neck Health Assessment Overview

• The presentation provides an overview on how to perform a thorough health assessment of the head and neck

Structures for Head and Neck Assessment

• Skull
• Hair
• Scalp & Face
• Neck
• Nose
• Ears
• Mouth & Pharynx
• Eyes

Cranium (8 Cranial Bones)

• Frontal (1)
• Parietal (2)
• Temporal (2)
• Occipital (1)
• Sphenoid (1)
• Ethmoid (1)

Face (14 Facial Bones)

• Nasal (2)
• Lacrimal (2)
• Inferior Nasal Concha (2)
• Maxilla (2)
• Zygomatic (2)
• Mandible (1)
• Vomer (1)
• Palatine (2)

Important Head and Neck Structures

• Salivary Glands
• Lymph nodes
• Tongue
• Sublingual gland
• Submandibular gland
• Parotid gland

Neck Composition

• Muscles
• Ligaments
• Cervical vertebrae
• Hyoid bone

Neck Contents

• Major blood vessels
• Larynx
• Trachea
• Thyroid gland

Key Neck Muscles

• Sternocleidomastoid
• Trapezius
• The paired muscles allow movement of and provide support to the head and neck

Major Neck Blood Vessels

• Internal jugular veins
• Carotid arteries
• Located bilaterally, parallel, and anterior to the sternomastoid muscles.
• Avoid compressing the carotid arteries when assessing.

Thyroid Gland

• The largest endocrine gland in the body
• Produces thyroid hormones that increase the metabolic rate of most body cells
• There are two lateral lobes that curve posteriorly on both sides of the trachea

Lymph Nodes

• Filters lymph removes bacteria and tumor cells from lymph
• Produces lymphocytes and anti bodies as a defense against invasion by foreign substance

Head: Inspection

• Inspect face and hair
• Overall appearance of the face, ensuring eyes and ears are at the same level
• Appropriate head size relative to the body
• Facial symmetry, looking for drooping on one side
• Symmetry of facial expressions and absence of involuntary movements
• The presence of any lesions
• Cranial nerve VII (facial nerve) should be tested

Head (Palpation)

• Palpate the cranium and inspect the hair for infestations, hair loss, skin breakdown or abnormalities
• Any masses or indentations
• Skin breakdown especially on the back of the head in immobile patients
• Check for infestations like lice, alopecia areata, nevus on the scalp
• Quantity, texture, and distribution of the hair

Head (Temporal Artery & Cranial Nerve V)

• Palpate the temporal artery bilaterally
• Have the patient bite down to feel the masseter and temporal muscles.
• Ask them to open their mouth against resistance
• Palpate the temporomandibular joint for grating or clicking
• Palpate the frontal and maxillary sinuses for tenderness
• Palpate for lumps or evidence of trauma, and assessing size, shape, and contour

Normal Head Findings

• Skull should be generally round, with prominences in the frontal and occipital area (Normocephalic)
• No tenderness upon palpation
• Scalp should be lighter in color than the complexion, and it can be moist or oily.
• No scars, lice, nits, or dandruff.
• Absence of lesions, tenderness or masses on palpation
• Hair can be black, brown, or burgundy
• Evenly distributed, covering the whole scalp without alopecia
• Hair may be thick or thin, coarse or smooth, and neither brittle nor dry
• Face shape may be oval or rounded and face is symmetrical
• No involuntary muscle movements are present, and patient can move facial muscles at will
• Cranial nerves V and VII are intact

Assessing the Neck

• Inspect the trachea
• Test cranial nerve XI (accessory nerve)
• Inspect for jugular vein distention
• Palpate the lymph nodes

Examining the Neck (Palpation)

• Palpate the trachea and thyroid gland
• Palpate the carotid artery, auscultate for bruits in the artery.

Thyroid Palpation (Posterior Approach)

• Client sits on a chair and the examiner stands behind them.
• Locate the cricoid cartilage to find the isthmus of the thyroid, directly below.
• Have the client swallow to feel for any enlargement of the thyroid isthmus.
• To examine lobes, ask the client to turn their head slightly toward the side being examined
• It will displace the sternocleidomastoid and while examiner moves the thyroid cartilage towards the side of the thyroid lobe to be examined
• The patient should swallow during the procedure
• The examiner can also palpate for thyroid enlargement by placing the thumb deep to and behind the sternocleidomastoid muscle, with the index and middle fingers placed deep to and in front of muscle

Anterior Approach

• The examiner stands in front of the client and uses the palmar surface of the middle and index fingers to palpate below the cricoid cartilage
• Ask the client to swallow while palpating
• Palpating the lobes of the thyroid is similar to the posterior approach where client is asked to turn the head slightly to one side and then the other, with the thyroid cartilage pushed towards the side of the lobe

Normal Neck Findings

• The neck is straight without visible masses or lumps, and it is symmetrical
• No jugular venous distension suggesting cardiac congestion
• Neck palpated above the suprasternal note using the thumb and index finger.
• The trachea is palpable and positioned in the midline
• Lymph nodes are palpated using palmar tips of the fingers in systemic circular movements, described in terms of size, regularity, consistency, tenderness, and fixation
• They may not be palpable or may be normally palpable in thin clients
• Thyroid non-tender if palpable, firm with smooth rounded surface, slightly movable, and less than 1 cm in size.
• The thyroid is initially observed by standing in front of the client and asking the client to swallow, while palpation can be done either by posterior or anterior approach
• Normally the thyroid is non-palpable, and the isthmus may be visible in a thin neck
• No nodules are palpable
• Auscultation may reveal bruits

Eyes and Their Function

• Eyelids (upper and lower)
• Eyelashes
• Conjunctiva
• Lacrimal apparatus
• Extraocular muscles

Eye Landmarks

• Lacrimal gland
• Lacrimal and gland ducts
• Eyelashes
• Sclera
• Iris
• Pupil
• Lacrimal duct
• Lacrimal sac
• Lacrimal lake
• Nasolacrimal duct

Extraocular Muscles

• Superior Rectus
• Inferior Rectus
• Lateral Rectus
• Medial Rectus
• Superior Oblique
• Inferior Oblique

Internal Structures of the Eye

• Layers: Sclera or the "window of the eye"
• Cornea permits the entrance of light, which passes through the lens to the retina
• Ciliary body
• Cornea
• Iris
• Lens
• Aqueous body
• Sclera
• Vitreous body

Visible Landmarks of The Eye

• Retina
• Choroid
• Optic nerve
• Optic disc area

Visual Fields

• Visual field refers to what a person sees with one eye
• Divided into four quadrants:
• Upper temporal
• Lower temporal
• Upper Nasal
• Lower Nasal

Collecting Subjective Ocular Data

• Health History
• History of Present Health Concerns (Visual Problems), (Other symptoms)
• Personal health history (Glaucoma, Macular Degeneration)
• Family History (Hx of Glaucoma, macular degeneration, refraction errors, allergies)
• Lifestyle and Health Practices

Assessing Tonometry

• Tonometry is used to measure pressure within the eye
• Normal eye pressure should be 10 to 21 mmHg
• Eye pressure > 22mmHg increases risk of developing Glaucoma

Macular Degeneration Testing

• Amsler Grid test involves looking at the center dot of the grid, and observing for any blurring, graying, distortion that should be marked on the grid

Collecting Objective Ocular Data

• Physical Examination
• Vision Test
• Inspection of External eye
• Inspection of Internal eye (ophthalmoscope)

Eye Acuity Chart (Snellen chart)

• Tests distant visual acuity
• The chart consists of lines of different letters stacked one above the other of varying sizes

Assessing Jaeger

• Near vision is assessed in clients over 40 years by holding the pocket screener or newspaper print 14" from the eye
• Clients who have decreased accommodation will move the card or newspaper further away to see it

Equipment for Ocular Assessment

• Snellen or E chart
• Hand-held Snellen card or near vision screener
• Penlight
• Opaque cards
• Ophthalmoscope

Physical Exam of the Eye

• General Routine Screening:
  • Test distant visual acuity
  • Test near visual acuity
  • Test visual fields for gross peripheral vision
  • Inspect the eyelids and eyelashes
  • Observe the position and alignment of the eyeball in the eye socket
  • Inspect the bulbar conjunctiva and sclera
  • Inspect the lacrimal apparatus
  • Inspect the iris and pupil
  • Assess pupillary reaction to light (direct & consensual) PERRLA

Focused Specialty Assessment of the Eye

- Perform corneal light reflex test
- Perform cover test
- Perform the cardinal fields of gaze test
- Inspect the palpebral conjunctiva
- Palpate the lacrimal apparatus
- Inspect the cornea and lens
- Assess the accommodation of pupils
- Use ophthalmoscope to inspect the optic disc, retinal vessels and background, fovea and macula, and anterior chamber.

Examination of the Eyes

• To inspect the eyes, examine the eyelids, pupils, sclera, and conjunctiva
• Look for: Is there swelling of the eye lids?
• Is the sclera white and shiny?
• Is the conjunctiva pink and not red and swollen?
• Check for strabismus and Anisocoria:Strabismus
• Do the eyes line up with another?
• Anisocoria are the pupils equal in size or is one pupil larger than the other?

Eye - Pupil Exam

• Are the pupils clear and not cloudy
• Normal pupil size should be 3 to 5 mm and equal at rest
• Testing cranial nerves III (oculomotor), IV (trochlear), VI (abducens) involves having the patient follow your pen light by moving it 12-14 inches from the patient's face in the six cardinal fields of gaze (start in the midline)
• Observe for the presence of nystagmus
• Dim the lights and have the patient look at a distant object, or perform the penlight shining test to check reactive to light

Examination of the Eyelids

• Inspect the eyelids for position and symmetry and palpate eyelids for the lacrimal glands
• Examination of the Eyes (conjunctiva)
• Examination of the Eyes - conjunctiva
• Ask the client to look down but keep his eyes slightly open. This relaxes the levator muscles, whereas closing the eyes contracts the orbicularis muscle, preventing lid eversion. Gently grasp the upper eyelashes and pull gently downward.

Cranial Nerve Visual Acuity (Optic Nerve)

• Test for visual acuity and peripheral vision
• Snellen chart or the illiterate E chart is used to assess visual acuity
• Each line has a standardized number at the end that indicates the degree of visual acuity that you can see
• The numerator 20 is the distance in feet of the test while the denominator is what's normal.

Considerations for Proper Visual Acuity Testing

• The room should be well-lighted
• Patients with corrective lenses should be assessed with and without lenses
• Only one eye should be tested at a time, others should be covered by an opaque card or eye cover and not the patient's fingers
• Start each line at various point and not just from top down

Normal Findings (Eyes)

• Eyebrows that are symmetrical in line with each other
• Common hair colors for eyebrows are black brown or blond
• Evenly distributed eyelashes that are color dependent on race
• Should be evenly distributed and turned outward
• Eyes that are evenly placed and inline without protrusion with equal palpebral fissure
• Upper eyelids that cover a small portion of the iris, cornea, and sclera when eyes are open without signs of drooping.

Normal Eye Findings

• Conjunctivae should be pinkish or red in color with presence of minute capillaries and should be moist without ulcers or foreign bodies
• Sclerae should be white in color without yellowish discoloration and some capillaries may be visible with pigmented position
• Corneal examination should be smooth, and transparency should be visible, allowing the features of the iris to be fully visible with a positive corneal reflex
• Pupils which range from 3-5mm or equal in size is normal however there can be brisky/sluggish when bright light is shined upon It

Examinating the ear & Otoscopy

• Inspect the auricles of the ears for parallelism, size position, appearance and skin color
• Palpate the auricles and the mastoid process for firmness of the cartilage, tenderness
• Inspect the auditory meatus or the ear canal for color, presence of cerumen, discharges, and foreign bodies

Proper Otoscopy Techniques

• ADULT: pull the pinna upward and backward to straighten the canal.
• CHILDREN: pull the pinna downward and backward to straighten the canal

Otoscopy Procdure

• Place the largest speculum that comfortably fits in the patient's ear on the head of the otoscope and turn on the light source.
• Angle the otoscope handle either directly downward or towards the patient's forehead
• Stabilize your otoscope hand by placing the fourth and fifth digits on the patient's head
• With your free hand, pull the ear up and in a posterior direction to straighten the canal as you insert the otoscope at a slightly downward angle.

Hearing Tests

• Whispered Voice Test which involves the examiner standing behind the patient and whispering some numbers to have the patient repeat those back.

Performing the Finger Rub test

• Place your fingers several centimeters from either ear
• Rub your fingertips together and ask the patient if they heard it.

Weber & Rinne Tests: Distinguishing Hearing Loss

• Weber test: Tests for lateralization and hearing and place a base of a vibrating tuning fork on the middle of the forehead and test the patient to hear. The sound should be heard the same without favor for one side.
• Rinne Test: Used for assessing air and bone conduction Place the base of a vibrating tuning fork on the mastoid process of the ear. Once the patient no longer hears a tone, immediately hold the "U" part of the fork over the outer ear and ask the patient if they can still hear it.
• Air conduction is normally greater than bone conduction, so the patient should still be able to hear the tuning fork next to the outer ear

Summary of Hearing Differentiations

• For Weber test: Sound lateralizes to affected ear for Conductive hearing Loss while Sound lateralizes to unaffected ear for for Sensorineural hearing Loss
• For Rinne test: BC > AC (negative ) for Conductive hearing Loss and AC > BC (positive ) for Sensorineural hearing Loss

Normal Ear Findings

• The earlobes are bean-shaped, parallel, and symmetrical
• The upper connection of the ear lobe is parallel with the outer canthus
• The auricles have firm cartilage on palpation
• The pinna recoils when folded.
• Lack of pain or tenderness in and around ear.
• The ear canal has normally some cerumen of inspection
• Tynpanic membrane appears flat on otoscope with translucent and translucent and pearly gray color

Proper Examination of the Nose and Paranasal Sinuses

• The external portion of the nose is inspected for Placement and symmetry
• Check for patency of nares
• Look for flaring of alae nasi and any discharge and palpate for bone or cartilage displacement and tenderness if any.

Paranasal Sinuses Palpatation

• Check by directing the lighted penlight on the side of the illumination.
• Palpate both cheeks and brow to see tenderness to sinusites

Function of Olfactory Nerve

To test the function of the olfactory nerve:

• First cover patient eyes
• Have the examiner placing a aromatic compound in order to easy distinguish Nose odor. i.e ( coffee,vinegar or alcohol swab)
• Ask the client to identify any odor with each side is tested separately

Normal Nose Findings

• Nose that are in midline without any discharges with flaring.
• Patient should be Patent and no palpation to nose and cartilages.
• No known tenderness reported by the patient
• Nasal septum in patient’s midline that are not perforated The examination showed nasal mucosa pinkish, which can turn to red if a increased redness from turbinates are present (Allergy Sign)

Proper Examination of Lips, Mouth, and Oropharynx

• Lips Inspected are symmetry with no abnormalities.
• Palpate while mouth, crepitus, deviations wide, tenderness during opening with the close
• Inspect the gums color, bleeding, retractions, number color, Alignment
• Palpate the tongue which may has visible texture along with assessing their uvula alignment and nerve function

Mouth Examination of Tonsils.

• Inspection of tonsils are for inflammation and sizing.
• Grading Chart Grade 1 behind pillars , Grade II between, Grade 3 uvula, Grade 3 Midline

Normal Examination Finindings for Mouth - Lip

• Mouth and oropharnx that is symmetrical
• Pinksh color
• No gum bleeding
• Moves smoothly without crepitus and jaw movement
• Teeth for children 28 adult 32 in White to color.
• Positioned to the midline. Pinkish Red color and without swelling

Normal Finding for Tongue

• Pinkish tint that has white buds with saliva
• Movement that doesnt has any lesions
• Gag reflexes are present