Chapter 14

Head, Face, and Neck, and

Regional Lymphatics
 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
 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
Structure: Head
Structure: head
 Cranial nerves
 Facial sensations of pain or touch are mediated
by the 3 sensory branches of cranial nerve V,
the trigeminal nerve.
 The expressions are formed by the facial
muscles, which are mediated by cranial nerve
VII, the facial nerve.
 The major neck muscles (sternomastoid and
trapezius), are innervated by cranial nerve XI.
 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
 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.
 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
Landmarks for finding thyroid
gland

10
11
 Structure and Function:
Lymphatics
 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.
Drainage Patterns of Lymph Nodes
 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
 Structure and Function:
Lymph Nodes (2 of 2)
 Jugulodigastric (tonsillar)
 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
Locations of Lymph Nodes
 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
Fontanels

19
 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: 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
 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
 Genetics and Environment
 Headache
 Leading cause of acute pain and lost productivity
 Classified by etiology and often misdiagnosed
 Types
 Tension-type headaches (TTH) most common
 Migraine – 2nd most common
 Episodic and Chronic
 Identify triggers
 Environment, foods, and/or stress
 Loss of productivity & impact on ADLs
 Subjective Data: Health History
 Headache
 Head injury
 Dizziness
 Neck pain, limitation of motion
 Lumps or swelling
 History of head or neck surgery
 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
 Red Flags
 Thunderclap Headache—severe,
reaching maximum intensity in
minutes.
 New severe HA, especially if older
than 50 years of age.
 HA triggered by coughing,
sneezing, straining, sexual
intercourse.
 HA triggered by change in
position, e.g., lying to standing.
 Prior HA pattern that now changes
significantly (worsening, never
goes away).
 HA with systemic signs/symptoms
(fever, rash, neck stiffness, weight
loss, personality changes)
 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
 duration/pattern of symptoms
• presence of associated symptoms
 treatment plan
• emergency, hospitalization, and/or medication
 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
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?
• Reaching developmental milestones
 For aging adults—patient-centered care
 Dizziness and/or neck pain
• How does it affect your daily activities?
 Inspect and Palpate 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
 Inspect 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
 Inspect and Palpate 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
 Inspect and Palpate 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 (alternate method)
 Auscultate thyroid for bruit, if enlarged
 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
Thyroid Palpation:
Anterior Approach
Thyroid Palpation:
Posterior Approach
 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
 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
 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
 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
 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
 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
 Physical Examination:
Aging Adult
 Temporal arteries
 may look twisted and prominent
 In some aging adults, a mild rhythmic tremor of head
may be normal
 Isolated head 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
 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
 TENSION
 Musculoskeletal
 Most common type of headache
 More common in women
 LOCATION: Usually both sides, across frontal,
temporal, and/or occipital region of head:
forehead, sides, and back of head
 Can be caused by lack of sleep, stress,
anxiety, poor posture.
 Pharmacologic and non-pharmacologic
treatment
 Migraine
 trigeminal nerve or vascular origin
 Moderate to severe intensity
 Can last 4-72 hours
 3 categories: migraine without aura, migraine
with aura, and chronic (>15 headache
days/month for 3 months)
 LOCATION: usually one sided, can occur bilaterally.
Pain behind eyes, temples, forehead.
 Pharmacologic and non-pharmacologic treatment
 4 stages of migraine
 Prodrome (hours to days before migraine):
change in mood, behavior, sensitivity to
light/sound/smell, hunger/cravings, fatigue,
yawning, constipation, or diarrhea
 Aura (5–60 min): visual changes (blind spots,
wavy lines, flashes of light); tingling in arm or
leg; vertigo; speech/language change
 Migraine attack (4–72 hr)
 Postdrome (24–48 hr): fatigue or irritability
 Causes of migraine/associated
symptoms
 Hormonal fluctuations
 Caffeine, alcohol
 Certain foods (cheese, chocolate, MSG)
 Hunger
 Change in sleep pattern
 Weather
 Physical activity
 Associated s/s: nausea,
vomiting, photo/phonophobia
 Cluster
 Rare HA that is intermittent, excruciating, unilateral, with
autonomic signs
 More common in men
 LOCATION: Always one-sided, behind or around the
eye, temple
 Severe pain
 Can last weeks (occur in clusters)
 Can wake patient up from sleep
 Associated s/s: lacrimation, nasal congestion, runny
nose, facial diaphoresis, agitation,
 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
 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
Fetal Alcohol Spectrum Disorders
(FASD)
 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
Thyroid Disorders: Graves Disease
 Physical presentation
neck and face
 Goiter
 Eyelid retraction
 Exophthalmos
Thyroid Disorders: Hypothyroidism
 Physical presentation
neck and face
 Puffy edematous face
 Periorbital edema
 Coarse facial features
 Coarse hair and
eyebrows
 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
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.