3- AH Head and neck PD Lec 2022.ppt

Physical Diagnosis Lecture: Head& Neck AHMAD HALIMI PA-C MSPAS EMAIL: [email protected] 1 General Considerations  The appearance of the head and face: their contours and textures often provide insight into the nature of illness.  Sunken cheeks, wasting of the temporal muscles, and flush...

Physical Diagnosis Lecture: Head& Neck AHMAD HALIMI PA-C MSPAS EMAIL: [email protected] 1 General Considerations  The appearance of the head and face: their contours and textures often provide insight into the nature of illness.  Sunken cheeks, wasting of the temporal muscles, and flushing of the face are important visible clues of systemic illness.  Some types of facies are pathognomonic of certain diseases. 2 General Considerations    The appearance of the face also gives information regarding a person’s psychological state: happy , sad , anxious. The WHO estimates that more than 200 million people in the world have enlarged thyroid glands known as a goiter. Greater that 200K in US yearly In the US, cancer of the head and neck constitute 5% of all malignancies in men and 2% in women. 3 General Considerations  Nearly 90% of head and neck cases are associated with poor dental hygiene, tobacco use, exposure to nickel and alcohol.  Head and Neck cancers : larynx , Nasal cavity, Hypopharynx, Salivary gland, and Oral cancer  Thyroid cancer is the most common endocrine cancer- women > men. 4 Anatomy and Physiology of the Head  The skull is composed of 22 bones, 14 in the face.  The facial skeleton is composed of the mandible, maxilla, the nasal, palatine, lacrimal and vomer bones.  The unpaired mandible forms the lower jaw. 5 Anatomy and Physiology of the Head  The cranial skeleton includes the frontal temporal, parietal and occipital bones.  The frontal bones form the forehead. The temporal bones form the anterolateral walls of the brain.  The mastoid process is part of the temporal bone and is important in diseases of the ear. 6 Anatomy and Physiology of the Neck https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.slideteam.net%2Fbusiness_powerpoint_diagrams %2F90804449-style-medical-1-musculoskeletal-1-piece-powerpoint-presentation-diagram-templateslide.html&psig=AOvVaw3sOkUBtBsdvqjnVGg0LrL&ust=1600295879788000&source=images&cd=vfe&ved=0CAIQjRxqFwoTCKDnzu2c7OsCFQAAAAAdAAAAABA f 7 Facial Bones 8 Muscles of the Head and Neck  The principal muscle of the mouth is the Orbicularis oris.The action of this muscle is to open and close the lips.  The Orbicularis oculi muscle surrounds the eye and closes the lids.  The Platysma muscle is a thin, superficial muscle of the neck and acts to pull the mandible down resulting in a mournful expression. 9 Muscles of the Face 1 0 Muscles Continued  The muscles of mastication include: the masseter, pterygoid, and temporalis. They insert on the mandible and effect chewing.  The Trigeminal nerve or 5th cranial nerve carries sensory fibers from the face, oral cavity, teeth and carries efferent fibers to the muscles of mastication. 1 1 Neck Structure and Physiology The neck is divided by the sternocleidomastoid muscle (SCM) into anterior and posterior triangles.  The SCM is a strong muscle that serves to raise the sternum during respiration. It has 2 heads- the sternal head arises from the manubrium sterni and the clavicular head originates on the sternal end of the clavicle.  The 2 heads unite and insert on the lateral aspect of the mastoid process. The SCM is innervated by the Spinal Accessory nerve- or 11th cranial nerve.  1 2 SCM Muscle video  https://youtu.be/eD3Ds3GIt9M 1 3 Anterior Triangle  The ANTERIOR triangle consists of the SCM, the lower border of the mandible and the midline of the neck anteriorly.  The Anterior triangle contains the thyroid gland, the larynx, pharynx, lymph nodes, submandibular salivary gland and fat. 1 4 Anterior Triangle of Neck 1 5 Posterior Triangle 1 6  The POSTERIOR triangle consists of the SCM (posterior border), the trapezius muscle posteriorly and the middle 1/3 of the clavicle inferiorly.  Important structures include: Spinal accessory nerve(Cranial Nerve XI),Phrenic nerve, subclavian artery, muscles, and lymph nodes 1 7 Posterior Triangle Thyroid Gland     The Thyroid gland envelops the upper trachea and consists of two lobes connected by an isthmus. It is the largest PURE endocrine gland in the body. The thyroid isthmus lies across the trachea just below the cricoid cartilage of the larynx. The lateral lobes extend along both sides of the larynx, reaching the level of the middle of the thyroid cartilage of the larynx. 1 8 Thyroid Gland 1 9 Thyroid Gland  The function of the thyroid is to produce thyroid hormone in accordance of the needs of the body.  The SCM muscle overlies the carotid sheath, which lies lateral to the pharynx.  The sheath contains the carotid artery, the internal jugular vein and the vagus nerve. 2 0 Carotid Sheath 2 1 Hyperthyroidism There are many symptoms of hyperthyroidism that involve many systems of the body. Some of these include: warm , moist skin, tremor , erythema, hyperhydrosis, anxiety, alopecia, palpitations, exophthalmos…etc.  The most common type of hyperthyroidism is the diffuse toxic goiter known as Grave’s disease. It is an autoimmune disease that can occur at any age.  2 2 Hyperthyroidism  Plummer’s disease accounts for 10% of hyperthyroidism and is caused by a single autonomously functioning thyroid adenoma.  Approximately 5% of the population has a single thyroid nodule larger than one centimeter. 90-95% of these are benign and need no therapy, however all should be investigated for malignancy. 2 3 Hypothyroidism  Hypothyroidism has a constellation of multisystemic symptoms related to high levels of circulating thyroid stimulating hormone. Some of these symptoms include, weight gain, fatigue, constipation, hair loss, dry skin, short attention span.  Hashimotos thyroiditis is the most common cause of hypothyoidism 2 4 2 5 Clinicopathologic Correlations  An enlarged thyroid is called a goiter and may be associated with hyperthyroidism, hypothyroidism or iodine deficiency  Although iodine deficiency is still a worldwide cause of thyroid enlargement, other important causes of goiter are infection, autoimmune disease, cancer, and isolated nodules. 2 6 Exopthalmos 2 7 data:image/jpeg;base64,/9j/4AAQSkZJRgABAQAAAQABAAD/2wC EAAkGBxQTEhUTExMWFRUXFxcXFhcXFxgXFhoYGBcXFxcXGBgYHiggGBolGxUVITEhJSkrLi4uFx8zODMtNygtLisBC goKDg0OGxAQGy0lHx8tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tLS0tNy0tLS0tLS0tN//AABEIALcBEwMBIgAC EQEDEQH/ xAAcAAACAwEBAQEAAAAAAAAAAAAEBQADBgIBBwj/xAA4EAABAwMCBAMIAQMEAgMAAAABAAIRAwQhMUEFElFhcYGRBhMiobHB0fDhFDLxFUJSYhYjBzOC/8QAGQEAAwEBAQAAAAAAAAAAAAAAAQIDAAQF/8QAJBEAAgICAgIBBQEAAAAAAAAAAAECEQMhEjEEQVETFCIy 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https:// img.medscape.com/ thumbnail_library/ ps_160314_goiters_80 0x600.jpg Lymph Nodes - Head and Neck  The head and neck contain hundreds of lymph nodes. The chains of these lymph nodes are named for their location.  Major site of B and T cell lymphocytes and other white blood cells . Help in the proper functioning of immune system. 2 9 Lymph Nodes Continued  Starting anteriorly, they are: Preauricular, post-auricular, occipital, submandibular, submental, superficial cervical, deep cervical, supraclavicular  Knowledge of the lymphatic drainage is important because the presence of an enlarged lymph node(s) may signal disease in the area draining into it. 3 0 Lymph Nodes – Head/Neck 3 1 Describe Abnormal Nodes  Location  Size (may be enlarged in infection or malignancy)  Shape (most nodes are round or ovoid; irregularly shaped or nodular nodes should make you think of malignancy)  Consistency (firm vs. fluctuant)  Delimitation (discrete vs. matted)  Mobility (mobile vs. fixed). If fixed, a neoplastic disease is more likely  Tenderness (Painful or not to palpation) 3 2 Neck Anatomy  3 3 The midline structures of the neck include the: hyoid bone, thyroid cartilage, cricoid cartilage, trachea and thyroid gland. https://www.google.com/url? sa=i&source=images&cd=&cad=rja& uact=8&ved=2ahUKEwih2Nvo4tXkAh UL2BoKHaUrAWcQjRx6BAgBEAQ&url =https%3A%2F %2Fwww.slideshare.net %2FSatinderSingh34%2Fsurgicalanatomy-ofneck&psig=AOvVaw0R2M1vn1XmEYT bqvbGNgtY&ust=1568738060173934 Tracheal Deviation   Tracheal deviation is a clinical sign that results from unequal intrathoracic pressure within the chest cavity. It is most commonly associated with tension pneumothorax but can also be caused by several acute and chronic health issues including Atelectasis: partial/complete collapse of lung lobe MNEMONIC: the trachea deviates toward the Opposite side with a pneumOthorax and the sAme side with Atelectasis. 3 4 Tracheal Deviation on CXR NORMAL 3 5 Symptoms of Neck 3 issues6 The most common symptoms related to the neck are neck mass and stiffness. Important questions to ask are:  When did you 1st notice the lump?  Does it hurt?  Does it change in size?  Have you had any recent infections in your mouth or ear?  Is there any hoarseness associated?  Is there a family history of thyroid cancer?  Is there a history of prior neck or thyroid radiation? Other Questions?? Symptoms of Neck issues  If there is pain, an infection is likely.  If it has been present for a few days, most commonly it is inflammatory whereas if present for months, most likely neoplastic.  Note the following: AGE of the patient. A lump in a patient younger than 20 may be an enlarged lymph node or a congenital mass such as a thyroglossal duct cyst. 3 7 Symptoms of Neck issues  The LOCATION of the mass is also important. Midline masses tend to be benign or congenital lesions. Lateral masses are frequently neoplastic or a benign Branchial Cleft cyst. Masses located in the lateral upper neck may be metastatic from tumors from the head and neck. Masses in the lower lateral neck may be metastatic from tumors in the breast or stomach.  Hoarseness- associated with a thyroid nodule suggests vocal cord paralysis due to impingement of the recurrent laryngeal nerve. 3 8 Neck Stiffness 3 9  Stiffness of the neck is usually caused by spasm of the cervical muscles and is commonly the cause of tension headache.  Acute/ Sudden onset of stiff neck, fever and headache should raise suspicion of possible meningeal irritation!! Impact of Head and Neck Disease on the Patient The head and neck are the most visible portions of the body. The shape of the eyes, mouth , nose and face are important to people. Many dislike their body image and wish to change it by cosmetic surgery.  Some require surgery to repair alterations caused by trauma while other patients go through very disfiguring surgeries to remove cancerous lesions.  The most common reaction to head and neck disease is depression.  4 0 Physical Examination  No special equipment is needed to examine this area of the body.  The examination consists of Inspection, Palpation and Auscultation (of the carotids and thyroid)  Specific techniques of exam will be discussed in PD lab. 4 1 Inspection        4 2 ALWAYS First step in your physical exam Note the position of the neck Check for symmetry- the trachea should be midline, note any enlargement, or unusual curvature. Note any scars, lesions or masses. If a mass is present describe it’s size, shape symmetry, consistency, mobility or tenderness. Note the color of the skin Note any pulsations or venous distention known as JVD= Jugular venous distension Inspect the head for any visible signs of trauma (look behind the ears for battle sign), asymmetry, abnormal facies. Battle Sign Abnormal Facies ecchymosis over mastoid process possible fracture of middle cranial fossa 4 3 Jugular venous Distension JVD https://www.google.com/imgres?imgurl=https%3A%2F %2Faccessmedicine.mhmedical.com%2Fdata%2Fbooks %2F1763%2Fatl_ch1_f002.png&imgrefurl=https%3A%2F %2Faccessmedicine.mhmedical.com%2Fcontent.aspx%3Fbookid %3D1763%26sectionid %3D125432768&docid=VFIJwRVtKaJgXM&tbnid=HxrfYEY-jcoKjM %3A&vet=10ahUKEwia04Og6NXkAhXNVt8KHR68CsEQMwh5KAswCw..i&w=491 &h=721&bih=908&biw=1680&q=battle %20sign&ved=0ahUKEwia04Og6NXkAhXNVt8KHR68CsEQMwh5KAswCw&iact= mrc&uact=8 https://www.google.com/url? sa=i&source=images&cd=&cad=rja&uact=8&ved=2ahUKEwj_gu3x59XkAhVPdhoKHVrUC9YQjRx6B AgBEAQ&url=https%3A%2F%2Fwww.pinterest.com%2Fpin %2F272960427388802435%2F&psig=AOvVaw1TOc4AD3DwR5vnZubrZfOn&ust=156873939762730 1 https://www.google.com/url? sa=i&source=images&cd=&ved=2ahUKEwjrlre_6NXkAhXLmeAKHaA6AcsQjRx6BAgBE AQ&url=https%3A%2F%2Fmeded.ucsd.edu%2Fclinicalmed %2Fheart.htm&psig=AOvVaw14vS9YyN1kuFCCsEOOV-PH&ust=1568739563800983 Raccoon Eyes - periorbital ecchymosis is a sign of basal skull fracture 4 4 Palpation 2nd Step in PE of Head and Neck  Palpation confirms the information obtained by inspection  All cranial bones should be palpated for tenderness and masses, deformities  Palpate all lymph nodes noting their size, shape , consistency, mobility, tenderness, delimitation  Palpate the thyroid- the anterior or posterior approach can be used.  4 5 Thyroid Anterior / Posterior technique 4 6 Thyroid on Physical Exam  The normal thyroid gland has the consistency of muscle  Unusual hardness is associated with scarring or malignancy  Softness or sponginess is often seen with toxic goiter  Tenderness of the thyroid is associated with acute infections or hemorrhage into the gland. 4 7 Thyroid on Physical Exam 4 8  If the thyroid is enlarged, the lobes should be auscultated with the bell and diaphragm for a bruit- a murmur heard when there is increased turbulence in a vessel.  Palpate for supraclavicular lymph nodes. Found Superior to the clavicle in the supraclavicular fossa. Left side called Virchow's nodes-found in gastric, ovarian, testicular, and kidney cancers Thyroid Cancer  Many patients with thyroid cancer in the early stages, do not experience symptoms.  Symptoms could include, a lump or nodule in the neck, hoarsness, difficulty speaking or swallowing, pain in the neck or throat and swollen lymph glands.  There are several types of thyroid cancer. 4 9 Thyroid Cancer  Papillary- most common (80-85%) and slow growing and usually grow in one lobe of the thyroid. (10-20% can involve both lobes)  Follicular-(5-10%) occurs in older individuals with a low iodine diet.  Medullary- (MTC) sporadic and familial and can be associated with other endocrine neoplasms. (MEN)  Anaplastic- (poorly differentiated)least common and most aggressive, most difficult to treat and control. 5 0 Sample Write up 5 1  Head: The skull is normocephalic/atraumatic (NC/AT).  Neck: Trachea midline. No masses, lesions, scars or pulsations. Neck is supple, non tender to palpation, no JVD  No palpable lymphadenopathy.  Thyroid: Non tender, without enlargement, no palpable masses Application in the field 5 2 https://encryptedtbn0.gstatic.com/images? q=tbn %3AANd9GcToj78KFDcWFwBlJ es6e9yAussv8HiTW2FC7g&us qp=CAU https:// medsphere.fi les.wordpres s.com/ 2017/04/107 5pxglidescope_0 2.jpg? w=1075 Application in the field Central Venous Catheter Insertion https://img.grepmed.com/ uploads/5450/ centralvenouscatheterizationmanagement-piccline-centrallineoriginal.jpeg https://cf-images.us-east1.prod.boltdns.net/v1/jit/ 2635130879001/f8d575ecb5e6-441d-b7bfbf17e58a8d31/main/ 1280x720/1m59s176ms/ match/image.jpg 5 3 Questions?? 5 4