HEAD AND NECK

ANATOMY AND PHYSIOLOGY

- carotid artery and internal jugular vein lie deep and run parallel to
sternocleidomastoid muscle along its
medial margin
- thyroid is largest endocrine gland

DEVELOPMENTAL VARIATIONS
A. INFANTS AND CHILDREN
- anterior and posterior fontanels are membranous spaces formed where
four cranial bones meet and
intersect
- spaces between cranial bones permit expansion of skull to
accommodate brain growth

B. PREGNANT WOMEN
- number of changes in thyroid gland and thyroid hormones
- physical signs of weight loss, tachycardia, eye signs, and bruit over
thyroid are suggestive of
hyperthyroidism

C. OLDER ADULTS
- thyroid gland becomes more fibrotic

I. SUBJECTIVE ASSESSMENT
A. LYMPHATIC
1. History of Present Illness
- head injury = state of consciousness after injury, predisposing
factors (seizure, poor vision,
light-headness), associated symptoms, medications
- headache = onset, duration, location, character (throbbing,
pounding, boring, shocklike, dull,
nagging), severity, pattern (worse in a.m. or p.m.) episodes,
associated symptoms
(nausea, vomiting, diarrhea) precipitating factors (fever,
fatigue, stress, food
additives), efforts to treat, medications
- stiff neck = injury or strain, fever, bacterial or viral illness,
character, predisposing factors
(unilateral vision, hearing loss), efforts to treat, medications
- thyroid problems = chg in temperature preference, swelling in
neck, chg in emotional
stability, increased prominence of eyes, tachycardia, chg in
menstrual flow and/or
bowel habits, medications
- face = symmetry, lesions, masses, involuntary movement
 2. Past Medical History - head trauma, radon or radium treatment,
headaches, surgery for tumor,
seizure disorder, thyroid dysfunction

3. Family History - headaches, thyroid dysfunction

4. Personal and Social History – employment (risk of head injury), stress,

potential risk for injury
(sports, unsafe environment), nutrition, use of alcohol and/or street
drugs

5. Developmental Variations
a. Infants and Children
- prenatal history (mother’s use of drugs or alcohol)
- birth history (vaginal, c-section, use of forceps)
- unusual head shape
- quality of head control
- acute illness (diarrhea, vomiting, fever, stiff neck, irritability)
- congenital anomalies
b. Pregnant Women
- presence of preexisting disease
- history of pregnancy-induced hypertension
- use of street drugs
- medications
c. Older Adults
- dizziness with head or neck movement
- weakness or impaired balance

II. OBJECTIVE ASSESSMENT

A. HEAD AND FACE
1. Inspection and Palpation (can start as soon as you see patient) of
Head
- inspect head position and facial features
- horizontal jerking or bobbing motion may be associated with
tremors
- head tilted or held to one side occurs with unilateral hearing or
vision loss
- facial features should be inspected for shape and symmetry with
rest, movement, and
expression
- facial nerve paralysis is suspected when entire side of face is
affected
- facial nerve weakness is suspected when lower face is affected
- tics (spasmodic muscular contractions of face, head, or neck)
should be noted
- note any edema, puffiness, coarsened features, prominent eyes,
hirsutism, lack of
expression, excessive perspiration, pallor, or pigmentation
variations
 - inspect skull for size, shape, and symmetry
- note any hair loss pattern, lesions, scabs, tenderness,
parasites, nits, or scaliness

**If no abnormalities found, can document as “normocephalic”

**Facial expressions are noted for pain, flat affect, mental capacity,
truthfulness**

2. Palpation – scalp should move freely over skull, and no tenderness,

swelling, or depressions on
palpation are expected
- note texture, color, distribution of hair
- should be smooth, symmetrically distributed, no splitting or
cracked ends
- coarse, dry and brittle hair is associated with
hypothyroidism
- fine, silky hair is associated with hyperthyroidism
- palpate temporal arteries and note course
- note thickening, harness or tenderness which may be
associated with temporal arteritis
- inspect for any asymmetry or enlargement of salivary glands
- if noted, palpate for discrete enlargement, noting if it is
fixed or movable, soft or
hard, tender or nontender

3. Percussion- not routinely performed

4. Auscultation – not routinely performed

- listen for bruits over skull and eyes
- use bell of stethoscope over temporal region, over eyes, and
below occiput

B. NECK
1. Inspection – inspect while in usual anatomic position, slight
hyperextension, and as patient swallows
- look for bilateral symmetry, alignment of trachea, landmarks of
anterior and posterior
triangles, and any subtle fullness at base of neck
- observe for any distention of jugular vein or prominence of carotid
arteries
- marked edema of neck is associated with local infections
- mass filling base of neck or visible thyroid tissue that glides
upward when patient swallows
may indicate an enlarged thyroid
- evaluate ROM by asking pt to flex, extend, rotate, and laterally
turn head and neck
- movement should be smooth and painless and should not
cause dizziness

2. Palpation – palpate trachea for midline position

 - hyoid bone, thyroid and cricoid cartilages should be smooth,
nontender and should move
under finger when pt swallows
- examination of thyroid gland involves inspection, palpation, and
auscultation
- ask pt to hyperextend head so that neck skin is tightened
- note any asymmetry
- after offering pt sip of water and positioning again in
hyperextended state, ask pt to
swallow
- enlarged thyroid gland may be visible (also may be
visible only from lateral
aspect)
- palpate thyroid for size, shape, configuration, consistency,
tenderness, and presence of any
nodules
- pt should be positioned to relax, with neck flexed slightly
forward and laterally toward
side being examined
- to facilitate swallowing, give pt a cup of water
- thyroid lobes, if felt, should be small, smooth, and free of nodules
- should rise freely with swallowing
- consistency should be firm yet pliable
- coarse tissue or gritty sensation implies inflammatory
process has been present
- if nodules are present, they are characterized by number,
smooth or irregular, soft or
hard, and tenderness indicates thyroiditis
- if gland is enlarges, auscultate with bell to hear vascular
bruit (soft, rushing sound)

3. Developmental Variations
a. Infants
- inspect for symmetry of shape, noting any prominent bulges
or swellings
- inspect scalp for scaling and crusting, dilated scalp veins,
presence of excessive
hair or unusual hairline
- birth trauma may cause swelling of scalp
caput succedaneum - subcutaneous edema over
presenting part of head at delivery
- most common form of birth trauma
- affected part feels soft, margins are poorly defined,
and edema, generally,
goes away in a few days
cephalhematoma – subperiosteal collection of blood and
bound by suture lines
- commonly found in parietal region, may not be
immediately obvious at birth
 - firm and edges are well defined; does not cross suture
lines
- may liquefy and become fluctuant on palpation
- bossing (bulging of skull) of frontal areas is associated with
prematurity and rickets
- in other areas may indicate cranial defects or
intracranial masses
- inspect face for spacing of features, symmetry, paralysis,
skin color, and texture
- note any jerking, tremors, or inability to move head in one
direction
- inspect neck for symmetry, size, and shape
- note presence of edema, distended neck veins,
pulsations, masses,
webbing, or excessive posterior cervical skin
- marked edema may indicate localized infection
- nuchal rigidity (resistance to flexion) is associated
with meningeal irritation
- palpate infant’s head, identifying suture lines and fontanels
(give important clues as
to what is going on inside the body)
- note any tenderness over scalp
- fontanels may be small or not palpable at birth
- 3rd fontanel located between anterior and posterior
fontanel may be an
expected variant but is common in infants with
Down Syndrome
- any palpable ridges in addition to expected may
indicate fractures
- palpate anterior fontanel for bulging or depression
- bulging fontanel feels tense and indicates infection or
increased intracranial
pressure
- cannot assume fontanel that is not bulging is free of
meningitis
- palpate scalp firmly above and behind ears to detect
craniotabes (softening of outer
table of skull)
- indication is a snapping sensation, similar to bounce
of ping-pong ball

III. COMMON ABNORMALITIES

A. HEADACHE- most common complaint and one of the most self-medicated
- not always benign
- history of insistent, severe, and recurrents must always be given
attention
- sometimes underlying cause is life threatening (brain tumor)

B. TORTICOLLIS – wryneck
- result of injury during delivery
 - head is tilted and twisted toward sternocleidomastoid muscle
- hematoma may be palpated shortly after birth
- firm, fibrous mass
- can occur in older children and adults as a result of trauma, muscle
spasms, viral infection, or drug
ingestion

C. SALIVARY GLAND TUMOR – may arise in any salivary gland, but most common in
parotid

D. HYPOTHYROIDISM / HYPERTHYROIDISM - thyroid hormone influences metabolism of

most cells in body
- overabundance or paucity can cause symptoms affecting many body
systems

System / Structure Hyperthyroidism Hypothyroidism

Affected
Constitutional (temp. Cool climate, wt. loss, nervous, easily Warm climate, wt gain, lethargic,
preference, wt., irritated, highly energetic complacent, disinterested
emotional state)
Hair Fine, w/loss; failure to hold perm. wave Coarse, w/ tendency to break
Skin Warm, fine, hyperpigment. at pressure Coarse, scaling, dry
pts.
Fingernails Thin, w/tendency to break; show Thick
onycholysis
Eyes Bilateral/Unilateral proptosis, lid Puffiness in periorbital region
retraction, dbl vision
Neck Goiter, chg in shirt neck size, pain over No goiter
thyroid
Cardiac Tachycardia., dysrhythmia, palpitations No chg noted
Gastrointestinal / Increased frequency of B.M.s; diarrhea Constipation / Menorrhagia
Menstrual rare/ Scant flow
Neuromuscular Increasing weakness, esp. in proximal Lethargic, but good muscular
muscles strength
E. MYXEDEMA – adult onset hypothyroidism associated with decreased metabolic
rate
- deposition of glycosaminoglycan in all organ systems leads to mucinous
edema of facial features

F. GRAVES DISEASE – thought to be autoimmune

- more common in women during 3rd and 4th decades of life
- multiple systems affected, often characterized by diffuse thyroid
enlargement, hyperthyroidism,
ophthalmologic, dermatologic, constitutional, menstrual, and
musculoskeletal pathologic
conditions
- pregnancy can make diagnosis more difficult
- presence of goiter may not be specific
- presence of wt. loss, marked tachy, eye signs, bruit over thyroid are
suggestive
G. ENCEPHALOCELE – protrusion of nervous tissue through defect in skull may occur
any place on scalp