Lymph Nodes Structure and Function

Lymph Nodes

• Preauricular lymph nodes are located in front of the ear
• Posterior auricular (mastoid) lymph nodes are located superficial to the mastoid process
• Occipital lymph nodes are located at the base of the skull
• Submental lymph nodes are located midline, behind the tip of the mandible
• Submandibular lymph nodes are located halfway between the angle and tip of the mandible
• Jugulodigastric lymph nodes are located under the angle of the mandible
• Superficial cervical lymph nodes are located overlying the sternomastoid muscle
• Deep cervical lymph nodes are located deep under the sternomastoid muscle
• Posterior cervical lymph nodes are located in the posterior triangle along the edge of the trapezius muscle
• Supraclavicular lymph nodes are located just above and behind the clavicle, at the sternomastoid muscle

Developmental Competence: Infants and Children

• Bones of the neonatal skull are separated by sutures and fontanels, which are spaces where the sutures intersect
• Fontanels allow for growth of the brain during the first year and gradually ossify
• The triangle-shaped posterior fontanel closes by 1 to 2 months, and the diamond-shaped anterior fontanel closes between 9 months and 2 years
• During the fetal period, head growth predominates
• Head size is greater than chest circumference at birth and reaches 90% of final size at 6 years old
• During infancy, trunk growth predominates, so that head size changes in proportion to body height
• Facial bones grow at varying rates
• In toddlers, the mandible and maxilla are small, and the nasal bridge is low

Inspection and Palpation of the Skull

• The skull should be assessed for size and shape
• Normocephalic skulls are round and symmetric
• Cranial bones with normal protrusions include the forehead, lateral edge of parietal bones, occipital bone, and mastoid process behind each ear
• The temporal area should be palpated to assess the temporal artery above the zygomatic bone between the eye and top of the ear

Inspection of the Face

• Facial structures should be symmetric
• Note any abnormal facial structures, such as coarse facial features, exophthalmos, changes in skin color or pigmentation, or abnormal swellings
• Note any involuntary movements (tics) in facial muscles; normally, none occur

Inspection and Palpation of the Neck

• Head and neck symmetry should be assessed, with the head positioned centered in the midline and accessory neck muscles symmetric
• Range of motion should be assessed, noting any limitations
• Muscle strength should be tested
• Observe for enlargement of glands and/or pulsations
• Lymph nodes should be palpated, noting location, size, shape, delimitation, mobility, consistency, and tenderness

Abnormal Findings: Primary Headaches

• Primary headaches are diagnosed by patient history with no abnormal findings on exam or laboratory results
• Types of headaches include tension, migraine, and cluster headaches
• Factors to review include definition, location, character, duration, quantity, and severity, and timing, as well as aggravating symptoms or triggers, associated symptoms, and relieving factors

Abnormal Findings: Pediatrics

• Hydrocephalus is a condition where obstruction of the drainage of cerebrospinal fluid results in excessive accumulation, increasing intracranial pressure, and enlargement of the head
• Down syndrome is a chromosomal abnormality with characteristic facial abnormalities, including upslanting eyes, flat nasal bridge, small, broad nose, protruding thick tongue, and ear dysplasia
• Plagiocephaly is a positional or deformational condition due to sleeping position
• Craniosynostosis is a premature closing of one or more cranial sutures that leads to head malformation
• Atopic (allergic) facies present with a variety of symptoms, including exhausted face, allergic shiners, Morgan lines, central facial pallor, and allergic gaping
• Fetal alcohol spectrum disorders (FASD) present with narrow palpebral fissures, epicanthal folds, thin upper lip, and midfacial hypoplasia
• Allergic salute and crease present with a transverse line on the nose in response to chronically repeated use of the hand to push the nose up and back

Abnormal Findings: Swellings of Head and Neck

• Congenital torticollis presents with a hematoma in one sternomastoid muscle, resulting in head tilt to one side and limited neck ROM to the opposite side
• Simple diffuse goiter (SDG) presents with chronic enlargement of the thyroid gland due to iodine deficiency
• Thyroid—multinodular goiter (MNG) presents with multiple nodules, indicating inflammation or multinodular goiter rather than a neoplasm
• Pilar cyst (Wen) presents as a benign growth that appears as a smooth, fluctuant swelling on the scalp
• Parotid gland enlargement presents with rapid, painful enlargement in response to mumps, blockage of duct, abscess, or tumor

Thyroid Disorders

• Graves disease presents with a goiter, eyelid retraction, and exophthalmos
• Hypothyroidism presents with a puffy, edematous face, periorbital edema, coarse facial features, coarse hair, and eyebrows