Head, Face, and Neck Assessment

• Topics to be covered include the head, face, and neck

Learning Objectives

• Understanding the normal anatomy and physiology of the head, face, and neck can be achieved.
• Key landmarks and structures identified during assessment of the head, face and neck.
• Skills to perform assessments of the head, face, and neck through inspection, palpation, and auscultation.
• Distinguishing between normal and abnormal findings during the aforementioned assessments.
• Properly documenting all assessment results using the correct medical terminology.
• Linking assessment results to any potential underlying pathologies is critical.

Anatomy and Physiology

• The head is the framework of the head.
• This area has two subsections: the cranium and the face.
• The cranium consists of the frontal, parietal, temporal, ethmoid, occipital, and sphenoid bones.
• The immovable sutures of the cranium are the sagittal, coronal, squamosal, and lamboid sutures.
• Cranial Nerves connect the brain to different parts of the head, neck, and trunk.
• Each has a Roman numeral between I and XII.
• Cranial nerve functions are sensory or motor.
• Sensory nerves involve the senses, such as smell, hearing, and touch.
• Motor nerves control the movement and function of muscles or glands.

The Neck

• Muscles, ligaments, and cervical vertebrae comprise the bone structure of the neck
• The neck contains the hyoid bone, major blood vessels, larynx, trachea, and thyroid gland.
• The C1-C7 vertebrae muscles are the sternomastoid and trapezius.
• Internal jugular veins and carotid arteries are the blood vessels present.
• The thyroid gland has two lateral lobes on both sides of the trachea and esophagus
• The lymph nodes in the head and neck create lymphocytes and antibodies of around 1 cm in size.
• Lymph nodes of the head and neck include preauricular, parotid, tonsillar, submental, submandibular, superficial cervical, posterior auricular, occipital, deep cervical, posterior cervical, and supraclavicular.

Cranial Nerves

• I: Sensory Olfactory Nerve (CN I)
• II: Sensory Optic Nerve (CN II)
• III: Motor Oculomotor Nerve (CN III)
• IV: Motor Trochlear Nerve (CN IV)
• V: Both Trigeminal Nerve (CN V)
• VI: Motor Abducens Nerve (CN VI)
• VII: Both Facial Nerve (CN VII)
• VIII: Sensory Vestibulocochlear Nerve (CN VIII)
• IX: Both Glossopharyngeal Nerve (CN IX)
• X: Both Vagus Nerve (CN X)
• XI: Motor Spinal Accessory Nerve (CN XI)
• XII: Motor Hypoglossal Nerve (CN XII)

Equipments Needed For Procedures

• Clean gloves to avoid infection transfer
• Cup of water for clients undergoing thyroid exams
• Penlight to directly illuminate the eyes, ears and throat
• Tongue depressor, used to depress the tongue to allow for intra-oral examination.
• Nasal speculum to permit viewing of the anterior third of the nasal airway.

Subjective Data

• Ask about lumps. Note time of onset, location, size, and texture
• Note any limited movement of the neck and describe
• Inquire about facial, neck, or head pain.
• Note any prior neck injuries and family history of head/neck cancer.

Head Inspection

• The head should be inspected for size, symmetry, and positioning

Size:

• Normal: Normocephalic
• Abnormal: Microcephalic, Macrocephalic, Mesocephalic

Symmetry:

• Normal: Symmetrical
• Abnormal: Asymmetrical

Position:

• Normal: Upright
• Abnormal: Tilted to one side

Abnormal Finding: Microcephaly

• Microcephaly causes an infant's head to be smaller than is expected for age and sex

Abnormal Finding: Macrocephaly

• Macrocephaly is the condition in which the head circumference of an infant is above two standard deviations or is above the 97th percentile

Head Inspection Symmetry

• Heads will be normal with a symmetrical look, and abnormal when asymmetrical

Abnormal Finding: Torticollis

• Torticollis, also known as wryneck or twisted neck, is a twisting of the neck that causes the head to rotate and tilt at an odd angle

Skull Palpation

• Skull palpation involves the texture and temporomandibular joint

Texture:

• Normal: Hard and smooth
• Abnormal: Lumps, Tenderness

Temporomandibular Joint:

• Normal: 3-6 cm vertical range with open mouth (snapping or popping is common)
• Abnormal: Pain, Swelling, Crepitus, Restricted Motion, Deviation to one side upon opening mouth.

Skull Inspection and Palpation

• Inspect & Palpate the skull by assessing cranial nerve VII, the Facial Nerve, and its motor function.
• Ask clients to smile, frown, raise eyebrows, show upper/lower teeth, keep eyes tightly closed while trying to open them.

Results:

• Normal: Symmetrical strength and movement of facial muscles
• Abnormal: Loss of or asymmetrical movement; muscle weakness, loss of nasolabial fold, drooping of side face/lower lid.

Inspect & Palpate the skull for cranial nerve V (Trigeminal Nerve) and its motor function for normal results:

• Symmetrical jaw movement; equal muscle strength in the jaw to prevent examiner from separating jaw.
• Abnormal results:
• Asymmetrical jaw movement and unilateral or bilateral decreased strength

Cranial Nerve V Trigeminal (sensory function):

• When eyelids blink when the cornea is touched using cotton shows normal sensation of light touch
• This shows:
  • absent, decreased, or unequal sensation.
  • absent blink suggests impairments.

Face Inspection

• Inspect face for the following: size and symmetry of facial features.
• Normal: Variable, symmetric
• Abnormal: Excessive large/small, asymmetric, distorted, lesions, masses.
• Face are inspected for facial expressions. -Normal: Variable, symmetric, centered head position
• Abnormal asymmetrical, Bell's palsy, parotitis, mask face

Nose Inspection

• Inspect for position, deformities, discharges, septal deviation, and flaring.
• Normal is when the nose is midline and symmetrical.
• No deviation, no flaring
• Abnormal results are:
  • misalignment of nose (previous.
  • trauma, congenital deformity, mass), + nasal flaring

Lips Inspection

• The lips are inspected for color, condition, and lesions.
• Pink lips, moist and intact without lesions indicate normal results.
• Results are abnormal with asymmetrical congenital deformity, trauma, pallor/redness, cyanosis, lesion, or trauma

Abnormal Finding: Lips

• Can also be assessed for breath odor/pursed lip breathing
• Normal: No unusual odor, no pursed lip breathing
• Abnormal: Halitosis

Oral Mucosa Inspection is for the following:

• Color, condition, lesions
• Normal Result: Pink lips, moist, intact, no lesions
• Abnormal Results: Abrasions, painful inflammation, ulcerations, white patches

Gums Inspection looks at the following:

• Color, condition, bleeding, lesions, presence of dentures
• Normal- pink, moist, intact, no lesions, no bleeding, no hypertrophy
• Abnormal- inflamed, bleeding gums, gingival hyperplasia

Teeth Inspection

• Number, color, and condition -normal adult has 32 teeth, while children have 20.
• white-light yellow
• no caries, no missing or loose teeth.
• Loose, malalignment, dental caries, teeth gray or with tetracycline result in an abnormal rating

Tongue Inspection

• Examine for color, texture, position, and mobility.
• Pink, moist, papillae intact, midline, and full mobility reflects normal results,
• Ulceration shows as abnormal, black hairy tongue, painful, or reddened

Hard/Soft, Palate Tonsils, & Uvula Inspection

• The hard soft palate is inspected with color, condition, lesions, drainage and exudates.
• Hard soft/hard palate has a pink and intact, tonsils are pink and symmetrical:
  • no exudates are shown
  • Uvula is symmetrical in rise.
• Any cleft palate will show in the palate -Reddened enlarged w/ is considered abnormal when tonsils have had exudates with an asymmetrical uvula rise

Test Swallow Reflex

• Normal results: (+) swallow and gag reflex
• Abnormal results: (-) swallow and gag reflex

Neck Inspection

• Inspecting the neck for appearance of the neck can result in the following:
• Normal results occur with a smooth, symmetrical head position
• Asymmetrical conditions show swelling and are considered abnormal

Palpating the Thyroid, Involves the following:

• Stand behind the client with thumb on the client's nape
• Have the client put their head back slightly
• Place index fingers just below the thyroid cartilage
• Have the client sip and swallow down water to check the rise of the thyroid assess both areas of the thyroid lobes

Tracheal Palpation

• Tracheal can be palpated by checking position and the the land marks.
• Normal -Midline position, symmetrical conditions result in identifiable land marks around the trachea
• Abnormal conditions will show asymetrical conditions deviating from the midline due to tumors or possible goiters

Lymph Node Palpation

• For assessment of size and the overall shape and appearance
• Normal results come without an usually visible appearance or results
  • The nodes are normally mobile, soft and don’t cause any tenderness or are not palpable
• abnormal is palpated with enlargement which would cause pain and possible signs of infection in irregular boarders that are greater than 1cm metastasic

Nursing Diagnosis

• Ineffective Airway Clearance (related to obstruction, swelling or trauma)
• Impaired Gas Exchange (related to respiratory distress or airway compromise)
• Acute Pain (related to headache, face or neck pain)
• Risk for Injury (Related to altered mental status, impaired vision, or balance)
• Impaired Skin Integrity (related to lesions, wounds, or infections)
• Impaired Swallowing (related to neurologic deficits or muscle weakness)
• Risk for Aspiration (related to impaired swallowing or altered mental status)
• Impaired Verbal Communication (related to the neurological deficits or facial trauma)
• Disturbed Sensory Perception (related to vision, hearing, and sensation loss)
• Self-Care Deficit (related to altered self-perception or physical limitations)