Head and NeckHead and NeckIncluding Regional Including Regional

LymphaticsLymphaticsN1037N1037

Head and Neck & Head and Neck & Regional LymphaticsRegional Lymphatics

Review and locate – The Review and locate – The Skull (bones of the Skull (bones of the

cranium and the face)cranium and the face)

Note the location of the Note the location of the CRANIAL BONESCRANIAL BONES

Frontal, Parietal, Occipital Frontal, Parietal, Occipital & Temporal& Temporal

Note the location of the Note the location of the sutures.sutures.

Coronal, Sagittal, Coronal, Sagittal, LambdoidLambdoid

Unite adjacent cranial Unite adjacent cranial bonesbones

Note facial bones.Note facial bones.

Nasal, Lacrimal, Maxilla, Nasal, Lacrimal, Maxilla, Sphenoid & Zygomatic bones.Sphenoid & Zygomatic bones.

Mandible (moves up, down, Mandible (moves up, down, sideways)sideways)

Head-facial musclesHead-facial muscles

Facial expressions are formed by Facial expressions are formed by facial musclesfacial muscles

Facial structures should be Facial structures should be symmetric.symmetric.

Facial muscles are innervated by Facial muscles are innervated by cranial nerve VIIcranial nerve VII

Note major Neck Note major Neck muscles.muscles.

Sternocleidomastoids and Sternocleidomastoids and trapezii musclestrapezii muscles

(each side of neck form (each side of neck form

2 triangles- anterior & 2 triangles- anterior & posterior cervical posterior cervical ))

Thyroid gland and Thyroid gland and other landmarksother landmarks

Thyroid gland - largest endocrine glandThyroid gland - largest endocrine gland -secretes T3 & T4 to regulate cellular -secretes T3 & T4 to regulate cellular

metabolismmetabolism -flattened butterfly shape structure-flattened butterfly shape structure

- 2 lateral lobes connected by isthmus- 2 lateral lobes connected by isthmus - isthmus rest on trachea, inferior to - isthmus rest on trachea, inferior to

the criocoid cartilage (highest point the criocoid cartilage (highest point Adam’s Apple)Adam’s Apple)

Note location of lymphaticsNote location of lymphatics1. Preauricular, 1. Preauricular,

2. post. auricular, 2. post. auricular,

3. occipital, 3. occipital,

4. submental, 4. submental,

5. submandibular, 5. submandibular,

6. Jugulodigastric or tonsillar,6. Jugulodigastric or tonsillar,

7. superficial cervical chain, 7. superficial cervical chain,

8. deep cervical chain, 8. deep cervical chain,

9. post. cervical, 9. post. cervical,

10. supraclavicular.10. supraclavicular.

Lymph NodesLymph Nodes

Usually less than 1 cm Usually less than 1 cm round or ovid in shaperound or ovid in shape smooth in consistencysmooth in consistency

when enlarged or tender - assess for when enlarged or tender - assess for infection or maligancy and the area infection or maligancy and the area the node drains ( see p322 example)the node drains ( see p322 example)

BLOOD SUPPLYBLOOD SUPPLY

Major arteries to head and neckMajor arteries to head and neck– common carotids bifurcate intocommon carotids bifurcate into– internal & external carotidsinternal & external carotids

Major veins from head and neckMajor veins from head and neck– internal an external jugular veins internal an external jugular veins – and subclavian veinsand subclavian veins

Head and Neck & Head and Neck & Regional LymphaticsRegional Lymphatics

Health HistoryHealth History

Subjective DataSubjective Data

Head and Neck & Regional Head and Neck & Regional Lymphatics- Health HxLymphatics- Health Hx

• facial or neck surgeryfacial or neck surgery

•• history of headaches or dizzinesshistory of headaches or dizziness

•• allergiesallergies• Neck pain, limitation of movementNeck pain, limitation of movement• Lumps or swelling, difficulty Lumps or swelling, difficulty

swallowing or chewing, history of swallowing or chewing, history of smokingsmoking

• head injurieshead injuries

Head: Inspect and Head: Inspect and palpate the skullpalpate the skull

Objective DataObjective Data

Head: Inspect and palpate the Head: Inspect and palpate the skullskull

Size and ShapeSize and Shape (I)Normocephalic:(I)Normocephalic: round, symmetric round, symmetric

and approximated to body size.and approximated to body size. (P)Shape(P)Shape: symmetric and smooth, no : symmetric and smooth, no

tenderness reported.tenderness reported.– Use finger pads on scalp & palpate all surfacesUse finger pads on scalp & palpate all surfaces– Assess contour, masses, depressions,tendernessAssess contour, masses, depressions,tenderness– Note deformities lumps and tenderness.Note deformities lumps and tenderness.

Head: Inspect and palpate the Head: Inspect and palpate the scalpscalp

(I) Scalp should be shiny, intact and (I) Scalp should be shiny, intact and without lesions or masses.without lesions or masses.– Part hair repeatedly and inspect scalpPart hair repeatedly and inspect scalp

(P) palpate with finger pads on the (P) palpate with finger pads on the scalp for lesions or massesscalp for lesions or masses

Head: Inspection of the faceHead: Inspection of the face (I) Symmetry of facial features:(I) Symmetry of facial features:

– Observe facial expression, shape and symmetry Observe facial expression, shape and symmetry of nose, eyes, eyebrows, mouth, earsof nose, eyes, eyebrows, mouth, ears

(I) Shape and features of face(I) Shape and features of face– Note shape of faceNote shape of face – Note swelling (edema) , abnormal features, Note swelling (edema) , abnormal features,

disproportionate structures (stroke, Bell’s Palsy disproportionate structures (stroke, Bell’s Palsy = cranial nerve 7 damage -facial nerve), and = cranial nerve 7 damage -facial nerve), and involuntary movement (the presence of tics -involuntary movement (the presence of tics -normally none occur)normally none occur)

(I) Facial expression(I) Facial expression: emotions: emotions– Note appropriateness to verbal and nonverbalNote appropriateness to verbal and nonverbal

Head: Palpate and Head: Palpate and Auscultation of MandibleAuscultation of Mandible

Temporal AreaTemporal Area (P)Temporal artery:(P)Temporal artery: above the cheek bone, between the above the cheek bone, between the

eye and the top of ear.eye and the top of ear.– Palpate with finger pads for pulsePalpate with finger pads for pulse

(P)Temporomandibular joint(P)Temporomandibular joint: articulates smoothly with : articulates smoothly with no limitation, no crepitus, no clickingno limitation, no crepitus, no clicking– use index and middle finger to palpate anterior to use index and middle finger to palpate anterior to

tragus of ear on both sidestragus of ear on both sides– ask pt to open & close mouthask pt to open & close mouth– observe smoothness of movement, any discomfortobserve smoothness of movement, any discomfort– clicking/crepitus could indicate arthritis or dislocationclicking/crepitus could indicate arthritis or dislocation

The Neck- Inspect and The Neck- Inspect and palpatepalpate

Objective DataObjective Data

The Neck- Inspect and palpateThe Neck- Inspect and palpate

What position do you ask the client to What position do you ask the client to assume while you inspect the neck?assume while you inspect the neck?

Head erect and still, sitting up Head erect and still, sitting up straight, head at your eye levelstraight, head at your eye level

The Neck- Inspect and palpateThe Neck- Inspect and palpateSymmetrySymmetry Head position: centered, midline, erect, stillHead position: centered, midline, erect, still Symmetry of the Sternocleidomastoid & trapezii Symmetry of the Sternocleidomastoid & trapezii

musclesmuscles ROM of neck (flexion, lateral rotation, lateral ROM of neck (flexion, lateral rotation, lateral

bending, extension, test muscle strength:Touch chin bending, extension, test muscle strength:Touch chin to chest, ear to shoulderto chest, ear to shoulder Turn head left to rightTurn head left to right Extend head backwardsExtend head backwards Motions should be smooth and controlled.Motions should be smooth and controlled. resists movement of shoulder shrug and head turn side to resists movement of shoulder shrug and head turn side to

sideside limited ROM with meningitis, muscle spasm, osteoarthritis limited ROM with meningitis, muscle spasm, osteoarthritis

The Neck- Inspect and palpateThe Neck- Inspect and palpate

(P) Muscles - should be symmetrical & (P) Muscles - should be symmetrical & without palpable masses or spasmswithout palpable masses or spasms– palpate Sternocleidomastoid and trapezii muscles palpate Sternocleidomastoid and trapezii muscles

for tenderness, masses, spasmsfor tenderness, masses, spasms– spasms due to infections, trauma, chronic spasms due to infections, trauma, chronic

inflammation, neoplasminflammation, neoplasm

The Neck- Inspect and palpateThe Neck- Inspect and palpateLymph NodesLymph Nodes (P) Lymph nodes - should not be palpable, but (P) Lymph nodes - should not be palpable, but

small discrete , movable nodes are often presentsmall discrete , movable nodes are often present Begin with preauricular lymph nodes and proceed in a Begin with preauricular lymph nodes and proceed in a

systematic fashion (1 to 10)systematic fashion (1 to 10) Use gentle pressureUse gentle pressure Deep cervical chain: tip head toward side Deep cervical chain: tip head toward side Supraclavicular Node:Supraclavicular Node: hunch shoulders & elbows hunch shoulders & elbows

forwardforwardtender nodes = inflamed due to infectiontender nodes = inflamed due to infectionfirm, non movable nodes may be = malignancyfirm, non movable nodes may be = malignancy

The Neck- Inspect and palpateThe Neck- Inspect and palpate

TracheaTrachea

Midline normal (note deviations)Midline normal (note deviations) Palpate for tracheal shift: space Palpate for tracheal shift: space

should be symmetric on both sides.should be symmetric on both sides.

The Neck- Inspect, palpate, The Neck- Inspect, palpate, auscultate auscultate

Thyroid GlandThyroid Gland inspect for swelling using lamp (ask to sip inspect for swelling using lamp (ask to sip

and swallow water) and swallow water) – thyroid tissue moves up with swallowingthyroid tissue moves up with swallowing observe for goiter - enlarged thyroidobserve for goiter - enlarged thyroid

palpate -anterior/posterior approachespalpate -anterior/posterior approaches– have pt slightly lower head to relax neck muscleshave pt slightly lower head to relax neck muscles– palpate isthmus for nodules, masses, tenderness or enlargement palpate isthmus for nodules, masses, tenderness or enlargement

while swallowingwhile swallowing– then displace/stabilize lobe on one side and palpate the other side then displace/stabilize lobe on one side and palpate the other side

while pt swallows while pt swallows gland is smooth, soft, & no tenderness/enlrgmt/massesgland is smooth, soft, & no tenderness/enlrgmt/masses

The Neck- Inspect, palpate, The Neck- Inspect, palpate, auscultateauscultate

auscultate lobes for bruit auscultate lobes for bruit – (use bell) (use bell) – no bruit should be presentno bruit should be presentbruits indicate blood supply r/t tumor or toxic bruits indicate blood supply r/t tumor or toxic

goiter.goiter.

Developmental ConsiderationsDevelopmental Considerations

Infant/ChildrenInfant/Children Skull and fontanelsSkull and fontanels

Pregnant FemalePregnant Female Cholasma on face = pregnancy maskCholasma on face = pregnancy mask

Aging AdultAging Adult Temporal arteries twisted and visibleTemporal arteries twisted and visible Rhythmic tremor of head may be presentRhythmic tremor of head may be present Perform ROM slowly to prevent dizzinessPerform ROM slowly to prevent dizziness