Chapter 14 Head, Face, Neck, and Regional Lymphatics 2 PDF

Chapter 14 Head, Face, and Neck, and Regional Lymphatics Copyright © 2020 by Elsevier Inc. All rights reserved.  Structure and Function: Head (1 of 2)  Skull is rigid box that protects brain. Includes bones of cranium and face Supported by c...

Chapter 14 Head, Face, and Neck, and Regional Lymphatics Copyright © 2020 by Elsevier Inc. All rights reserved.  Structure and Function: Head (1 of 2)  Skull is rigid box that protects brain. Includes bones of cranium and face Supported by cervical vertebra  Cranial bones Frontal Parietal Occipital Temporal  Sutures—adjacent cranial bones mesh at sutures Coronal Sagittal Lambdoid Copyright © 2020 by Elsevier Inc. All rights reserved.  Structure and Function: Head (2 of 2)  14 facial bones also articulate at sutures.  Facial expressions formed by facial muscles, which are mediated by cranial nerve VII, the facial nerve  Two pairs of salivary glands accessible to examination on the face: Parotid glands are in cheeks over mandible, anterior to and below ear; the largest of salivary glands, they are not normally palpable. Submandibular glands beneath mandible at angle of jaw  Third pair, sublingual glands, lies in floor of mouth.  Temporal artery lies superior to temporalis muscle, and pulsation is palpable anterior to ear. Copyright © 2020 by Elsevier Inc. All rights reserved. Structure: Head Copyright © 2020 by Elsevier Inc. All rights reserved.  Structure and Function: Neck  Neck delimited by Base of skull and inferior border of mandible above, and by manubrium sterni, clavicle, first rib, and first thoracic vertebra below  Think of neck as conduit of many structures. Vessels, muscles, nerves, lymphatics, and viscera of respiratory and digestive systems Internal carotid branches off common carotid and runs inward and upward to supply brain. External carotid supplies face, salivary glands, and superficial temporal area. Copyright © 2020 by Elsevier Inc. All rights reserved.  Structure and Function: Neck Muscles  Major neck muscles Sternomastoid and trapezius are innervated by cranial nerve XI.  Sternomastoid enables Head rotation and flexion and divides each side of neck into two triangles: anterior and posterior triangles  Two trapezius muscles move shoulders and extend and turn head. Copyright © 2020 by Elsevier Inc. All rights reserved.  Structure and Function: Thyroid  Endocrine gland Straddles trachea in middle of the neck  Synthesizes and secretes Thyroxine (T4) and triiodothyronine (T3), which are hormones that stimulate rate of cellular metabolism  The gland has two lobes Connected in middle by a thin isthmus and above that by the cricoid cartilage or upper tracheal ring  Thyroid cartilage Small palpable notch in upper edge (“Adam’s apple” in males) Cricoid cartilage or upper tracheal ring Isthmus of the thyroid gland Copyright © 2020 by Elsevier Inc. All rights reserved. Structures of Neck Copyright © 2020 by Elsevier Inc. All rights reserved.  Structure and Function: Lymphatic System  Major part of immune system Detects and eliminates foreign substances from body  Rich supply of lymph nodes Greatest supply is in head and neck.  Lymphatic drainage Helps to prevent potentially harmful substances from entering the circulation You should be familiar with direction of drainage patterns of lymph nodes. Copyright © 2020 by Elsevier Inc. All rights reserved. Drainage Patterns of Lymph Nodes Copyright © 2020 by Elsevier Inc. All rights reserved.  Structure and Function: Lymph Nodes (1 of 2)  Preauricular In front of ear  Posterior auricular (mastoid) Superficial to mastoid process  Occipital At base of skull  Submental Midline, behind tip of mandible  Submandibular Halfway between angle and tip of mandible Copyright © 2020 by Elsevier Inc. All rights reserved.  Structure and Function: Lymph Nodes (2 of 2)  Jugulodigastric Under angle of mandible  Superficial cervical Overlying sternomastoid muscle  Deep cervical Deep under sternomastoid muscle  Posterior cervical In posterior triangle along edge of trapezius muscle  Supraclavicular Just above and behind clavicle, at sternomastoid muscle Copyright © 2020 by Elsevier Inc. All rights reserved. Locations of Lymph Nodes Copyright © 2020 by Elsevier Inc. All rights reserved.  Developmental Competence: Infants and Children (1 of 2)  Bones of neonatal skull are separated by sutures and fontanels, spaces where the sutures intersect. These membrane-covered “soft spots” allow growth of brain during first year; gradually ossify.  Closure of fontanels Triangle-shaped posterior fontanel closes by 1 to 2 months. Diamond-shaped anterior fontanel closes between 9 months and 2 years.  During fetal period, head growth predominates. Head size is greater than chest circumference at birth and reaches 90% of final size at 6 years old. Copyright © 2020 by Elsevier Inc. All rights reserved.  Developmental Competence: Infants and Children (2 of 2)  During infancy, trunk growth predominates so that head size changes in proportion to body height.  Facial bones grow at varying rates. In toddler, mandible and maxilla are small and nasal bridge is low.  Lymphoid tissue Well developed at birth and grows to adult size when the child is 6 years old  In adolescence facial hair also appears on boys at this time: first on upper lip, then on cheeks and lower lip, and last on the chin. noticeable enlargement of the thyroid cartilage occurs, and with it, the voice deepens. Copyright © 2020 by Elsevier Inc. All rights reserved.  Developmental Competence  Pregnant female Thyroid gland enlarges slightly during pregnancy as a result of hyperplasia of tissue and increased vascularity.  Aging adult Facial bones and orbits appear more prominent. Facial skin sags resulting from decreased elasticity, decreased subcutaneous fat, and decreased moisture in skin. Lower face may look smaller if teeth have been lost. Copyright © 2020 by Elsevier Inc. All rights reserved.  Culture and Genetics  Headache Leading cause of acute pain and lost productivity  Classified by etiology and often misdiagnosed  Chronic migraine More than 15 days per month  Gender difference More common in females than males with peak in midlife seen equally  Ethnic difference More prevalent among Caucasian and Hispanic population  Various etiological theories proposed Copyright © 2020 by Elsevier Inc. All rights reserved.  Subjective Data: Health History  Headache  Head injury  Dizziness  Neck pain, limitation of motion  Lumps or swelling  History of head or neck surgery Copyright © 2020 by Elsevier Inc. All rights reserved.  Health History Questions: Headaches  Ask about onset pattern characteristics. location pattern. pain characteristics. course and duration. precipitating factors. associated factors. alleviating factors. what makes it worse. presence of comorbidities. medication history. patient-centered care. Copyright © 2020 by Elsevier Inc. All rights reserved.  Health History Questions: Head Injury  Ask about onset, setting, and description of injury. changes in levels of consciousness. loss of consciousness and/or fall history of comorbidity. location of injury. pattern of symptoms. presence of associated symptoms. treatment plan emergency, hospitalization, and/or medication. Copyright © 2020 by Elsevier Inc. All rights reserved.  Other Health History Questions  Dizziness Provide a description of “feeling” in patient’s own words Associated with change of position, nausea, and/or vomiting  Neck pain Onset, location, associated symptoms, limitation of ROM, precipitating factors, stress Focus on patient-centered care  Lumps or swelling History of recent infection, radiation, smoking, alcohol, difficulty swallowing, thyroid issues  History of head or neck surgery Type of surgery, reason for surgery, response to surgery Copyright © 2020 by Elsevier Inc. All rights reserved. Additional Health History Questions  For infants and children Maternal alcohol or drug use? Type of delivery? Vaginal or by cesarean section? Any difficulty? Use of forceps? Growth pattern? Was it on schedule?  For aging adults—patient-centered care Dizziness and/or neck pain How does it affect your daily activities? Copyright © 2020 by Elsevier Inc. All rights reserved.  Inspection and Palpation of the Skull  Size and shape Normocephalic: round and symmetric Assess shape: place fingers in person’s hair and palpate scalp Cranial bones that have normal protrusions: Forehead, lateral edge of parietal bones, occipital bone, and mastoid process behind each ear  Temporal area Palpate temporal artery above zygomatic (cheek) bone between eye and top of ear Copyright © 2020 by Elsevier Inc. All rights reserved.  Inspection of the Face  Facial structures Always should be symmetric.  Note facial expression and appropriateness to behavior or reported mood.  Note any abnormal facial structures Coarse facial features, exophthalmos, changes in skin color or pigmentation, or abnormal swellings  Note any involuntary movements (tics) in facial muscles; normally none occur. Copyright © 2020 by Elsevier Inc. All rights reserved.  Inspection and Palpation of the Neck (1 of 2)  Head and neck symmetry Head position is centered in midline, and accessory neck muscles should be symmetric. Head should be held erect and still.  Range of motion Note any limitations. Test muscle strength. Observe for enlargement of glands and/or pulsations.  Lymph nodes Palpate nodes noting location, size, shape, delimitation, mobility, consistency, and tenderness. Copyright © 2020 by Elsevier Inc. All rights reserved.  Inspection and Palpation of the Neck (2 of 2)  Trachea Should be midline Palpate for any tracheal shift Note any deviation from midline  Thyroid gland Difficult to palpate; check for enlargement, consistency, symmetry, and presence of nodules Position patient for best approach Posterior approach Anterior approach Auscultate thyroid for bruit, if enlarged. Copyright © 2020 by Elsevier Inc. All rights reserved.  Examining Lymph Nodes  Using a gentle circular motion of finger pads, palpate lymph nodes.  Beginning with preauricular lymph nodes in front of ear, palpate the 10 groups of lymph nodes in routine order  Many nodes are closely packed, so you must be systematic and thorough in your examination.  Do not vary sequence or you may miss some small nodes. Copyright © 2020 by Elsevier Inc. All rights reserved. Thyroid Palpation: Anterior Approach Copyright © 2020 by Elsevier Inc. All rights reserved. Thyroid Palpation: Posterior Approach Copyright © 2020 by Elsevier Inc. All rights reserved.  Physical Examination: Infants and Children (1 of 2)  Skull Measure infant’s head at each visit up to age 2 years and yearly up to age 6 years. Note infant’s head posture and head control; infant can turn head side to side by 2 weeks. Two common variations in newborn cause shape of skull to look markedly asymmetric due to birth trauma: Caput succedaneum: edematous swelling that is self-limiting and extends across suture lines Cephalohematoma: subperiosteal hemorrhage, well defined over one cranial bone over periosteum, reabsorbed during first few weeks of life Copyright © 2020 by Elsevier Inc. All rights reserved.  Physical Examination: Infants and Children (2 of 2)  Skull Molding Overriding of the cranial bones during birth process that resolves over a few days or a week Positional molding (positional plagiocephaly) Flattening of the head due to infant sleeping position Fontanels Observe anterior and posterior fontanel. Head and neck control Observe for appearance of tonic neck reflex which disappears between 3 and 4 months of age. Copyright © 2020 by Elsevier Inc. All rights reserved.  Physical Examination: Infants and Children: Face  Check facial features for symmetry, appearance, and swelling. Note symmetry of wrinkling when infant cries or smiles (e.g., both sides of lips rise and both sides of forehead wrinkle). Normally, no swelling is evident.  Parotid gland enlargement best seen when child looks up; swelling appears below angle of jaw Copyright © 2020 by Elsevier Inc. All rights reserved.  Physical Examination: Infants and Children: Neck  An infant’s neck looks short; it lengthens during the first 3 to 4 years.  Assess muscle development with gentle passive ROM. Cradle infant’s head with your hands and turn it side to side and test forward flexion, extension, and rotation. Note resistance to movement, especially flexion.  During infancy, cervical lymph nodes are not palpable normally, but child’s lymph nodes are palpable. Palpable nodes less than 3 mm are normal.  Children have a higher incidence of infection, so you will expect a greater incidence of inflammatory adenopathy; no other mass should occur in neck. Copyright © 2020 by Elsevier Inc. All rights reserved.  Infants and Children: Special Procedures  Percussion With an infant, you may directly percuss with your plexor finger against head surface. This yields a resonant or “cracked pot” sound, which is normal before closure of fontanels.  Auscultation Bruits are common in skull of children under 4 or 5 years of age or children with anemia. Systolic or continuous; heard over temporal area Copyright © 2020 by Elsevier Inc. All rights reserved.  Physical Examination: Pregnant Female  During second trimester chloasma may show on face. A blotchy, hyperpigmented area over cheeks and forehead that fades after delivery  Thyroid gland may be palpable normally during pregnancy. Copyright © 2020 by Elsevier Inc. All rights reserved.  Physical Examination: Aging Adult  Temporal arteries may look twisted and prominent.  In some aging adults, a mild rhythmic tremor of head may be normal. senile tremors are benign and include head nodding and tongue protrusion.  If some teeth have been lost lower face looks unusually small, with mouth sunken in.  Neck may show an increased concave curve to compensate for kyphosis.  Maintain patient safety by indicating patient perform ROM and position changes slowly minimize potential for dizziness. Copyright © 2020 by Elsevier Inc. All rights reserved.  Abnormal Findings: Primary Headaches  Diagnosed by patient history with no abnormal findings on exam or laboratory results  Types of headaches: Tension, migraine, and cluster  Factors to review: Definition, location, character, duration, quantity and severity, and timing Aggravating symptoms or triggers, associated symptoms and relieving factors, effort to treat Copyright © 2020 by Elsevier Inc. All rights reserved.  Abnormal Findings: Pediatrics (1 of 2)  Hydrocephalus Obstruction of drainage of cerebrospinal fluid results in excessive accumulation, increasing intracranial pressure, and enlargement of the head,  Down syndrome Most common chromosomal abnormality with characteristic facial abnormalities Upslanting eyes with inner epicanthal folds Flat nasal bridge and small, broad nose Protruding thick tongue and ear dysplasia Broad neck with webbing and small hands with single palmar crease  Plagiocephaly Positional or deformational due to sleeping position Copyright © 2020 by Elsevier Inc. All rights reserved.  Abnormal Findings: Pediatrics (2 of 2)  Craniosynostosis Premature closing of one or more cranial sutures that leads to head malformation  Atopic (allergic) facies A variety of presentations seen in children who have chronic allergies Include exhausted face, allergic shiners, Morgan lines, central facial pallor and allergic gaping  Fetal alcohol spectrum disorders (FASD) Narrow palpebral fissures, epicanthal folds, thin upper lip, and midfacial hypoplasia  Allergic salute and crease Appearance of transverse line on the nose in response to chronically repeated use of hand to push the nose up and back Copyright © 2020 by Elsevier Inc. All rights reserved. Fetal Alcohol Spectrum Disorders (FASD) Copyright © 2020 by Elsevier Inc. All rights reserved.  Abnormal Findings: Swellings of Head and Neck  Congenital torticollis Hematoma in one sternomastoid muscle, probably injured by intrauterine malposition, results in head tilt to one side and limited neck ROM to opposite side  Simple diffuse goiter (SDG) Endemic goiter due to iodine deficiency that results in chronic enlargement of the thyroid gland  Thyroid—multinodular goiter (MNG) Multiple nodules usually indicate inflammation or multinodular goiter rather than a neoplasm; however, suspect any rapidly enlarging or firm nodule  Pilar cyst (Wen) Benign growth that presents as smooth, fluctuant swelling on scalp  Parotid gland enlargement Rapid painful enlargement seen in response to mumps, blockage of duct, abscess, or tumor Copyright © 2020 by Elsevier Inc. All rights reserved. Thyroid Disorders: Graves Disease  Physical presentation neck and face Goiter Eyelid retraction Exophthalmos Copyright © 2020 by Elsevier Inc. All rights reserved. Thyroid Disorders: Hypothyroidism  Physical presentation neck and face Puffy edematous face Periorbital edema Coarse facial features Coarse hair and eyebrows Copyright © 2020 by Elsevier Inc. All rights reserved.  Abnormal Facial Appearances Associated with Chronic Illnesses  Acromegaly Elongated head, massive face, overgrowth of nose, lower jaw, heavy eyebrow ridge, and coarse facial features  Cushing syndrome Classic “moonlike” face, red cheeks, and hirsutism  Bell palsy Paralysis on one side of the face as a result of LMN lesion  Stroke or brain attack UMN lesion leading to paralysis of lower facial muscles  Parkinson syndrome Classic “maskline” appearance, elevated eyebrows, staring gaze, oily skin and drooling due to dopamine deficiency  Cachectic appearance Sunken eyes, hollow cheeks, and defeated expression that accompanies chronic wasting diseases Copyright © 2020 by Elsevier Inc. All rights reserved. Summary Checklist: Head, Face, and Neck, including Regional Lymphatics Examination  Inspect and palpate the skin. General size and contour. Note any deformities. Palpate temporal artery and temporomandibular join (TMJ) joint.  Inspect and palpate the face. Observe facial expression. Cranial nerve VII: symmetry of movement. Observe for any abnormal movements.  Inspect and palpate the neck. Active ROM, potential enlargement and position of trachea  Auscultate thyroid (if enlarged) for bruit. Copyright © 2020 by Elsevier Inc. All rights reserved.