Head and Neck Assessment - DOC

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					                                  Head and Neck Assessment
A head and neck assessment focuses on the cranium, face, thyroid glands, and lymph nodes structures
contained within the head and neck.

The Head
 The framework of the head is the skull, which can be divided into two subsections, the cranium and the
Cranium; it consists of eight bones:
     Frontal”1”
     Parietal”2”
     Temporal”2”
     Occipital”1”
     Ethmoid”1”
     Sphenoid”1”

Face; the face consists of 14 bones:
    Maxilla (2)
    Zygomatic “cheek” (2)
    Inferior conchae (2)
    Nasal (2)
    Lacrimal (2)
    Palantine (2)
    Vomer (1)
    Mandible” jaw” (1)

The Hair: Note its quantity, distribution, texture, and pattern of loss, if any. You may see loose flakes of
The Scalp: Part the hair in several places and look for scaliness, lumps, nevi, or other lesions.
The Skull: Observe the general size and contour of the skull. Note any deformities, depressions, lumps,
or tenderness. Familiarize yourself with the irregularities in a normal skull, such as those near the suture
lines between the parietal and occipital bones.
The Face: Note the patient’s facial expression and contours. Observe for asymmetry, involuntary
movements, edema, and masses.
The Skin: Observe the skin, noting its color, pigmentation, texture, thickness, hair distribution, and any

 All of facial bones are immovable except for the mandible, which is allowed free movement at the
  temporomandibular joint. These bones give shape to the face.
 A major artery, the temporal artery, is located between the eye and the top of the ear. Two other
  important structures located in the facial region are the parotid and Submandibular salivary glands.
 The parotid glands are located on each side of the face, anterior and inferior to the ear and behind the
  mandible. The submandible glands are located inferior to the mandible, underneath the base of the

The structure of the neck is composed of muscles, ligaments, and the cervical vertebrae. Contained
within the neck are the hyoid bone, several major blood vessels, the larynx, trachea, and the thyroid
gland, which is in the anterior triangle of the neck.

Muscles and Cervical Vertebrae
The sternomastoid “sternocleiodomastoid” and trapezius muscles are two of the paired muscles that
allow movement and provide support to the head and neck. This sternomastoid muscle rotates and flexes
the head, whereas the trapezius muscle extends the head and moves the shoulders. The eleventh cranial
nerve is responsible for muscle movement that permits shrugging of the shoulders and turning the head
against resistance by the sternomastoid muscles. The cervical vertebrae “C1 through C7” are located in
the posterior neck and support the cranium. The vertebrae prominence is C7, which can easily be
palpated when the neck is flexed. Using C7 as a landmark will help you locate other vertebrae.

Blood Vessels
The internal jugular veins and carotid arteries are located bilaterally, parallel and anterior to the
sternomastoid muscles.

Thyroid Gland
The thyroid gland is the largest endocrine gland in the body. It produces thyroid hormones that increase
the metabolic rate of most body cells. The thyroid gland is surrounded by several structures that are
important to palpate for accurate location of the thyroid gland. The trachea, through which air enters the
lungs, is composed of C-shaped hyaline cartilage rings. The first upper tracheal ring, called the cricoids
cartilage. The thyroid cartilage” Adam’s apple” is larger and located just above the cricoids cartilage.
The thyroid gland consists of two lateral lobes that curve posterior on both sides of the trachea and
esophagus and are mostly covered by sternomastoid muscles.

Palpation: The thyroid can be examined while you stand in front of or behind the patient. Exam from
behind the patient is described below:

   1. Stand behind the patient and place the middle three fingers of either hand along the mid-line of
      the neck, just below the chin. Gently walk them down until you reach the top of the thyroid
      cartilage, the first firm structure with which you come into contact. Use gentle pressure,
      otherwise this can be uncomfortable. Make sure that you tell your patients what you're doing so
      they know you're not trying to choke them! The cartilage has a small notch in its top and is
      approximately 1.5-2 cm in length. As you cannot actually see the area that you're examining, it
      may be helpful to practice in front of a mirror. You can also try to identify and feel the structures
      from the front while looking at the area in question before performing the exam from behind.

   2. Walk down the thyroid cartilage with your fingers until you come to the horizontal groove which
      separates it from the cricoid cartilage (the first tracheal ring). You should be able to feel a small
      indentation (it barely accepts the tip of your finger) between these 2 structures, directly in the
      mid-line. This is the crico-thyroid membrane, the site for emergent tracheal access in the event of
      upper airway obstruction.

   3. Continue walking down until you reach the next well defined tracheal ring. Now slide the three
      fingers of both hands to either side of the rings. The thyroid gland extends from this point
      downwards for approximately 2-3 cm along each side. The two main lobes are connected by a
      small isthmus that reaches across mid-line and is almost never palpable. Apply very gentle
      pressure when you palpate as the normal thyroid tissue is not very prominent and easily
      compressible. If you're unsure or wish confirmation, have the patient drink water as you palpate.
      The gland should slide beneath your fingers while it moves upward along with the cartilagenous
      rings. It takes a very soft, experienced touch in order to actually feel this structure, so don't be
      disappointed if you can't identify anything.

   4. Pay attention to several things as you try to identify the thyroid: If enlarged (and this is a
      subjective sense that you will develop after many exams), is it symmetrically so? Unilateral vs.
      bilateral? Are there discrete nodules within either lobe? If the gland feels firm, is it attached to
      the adjacent structures (i.e. fixed to underlying tissue.. consistent with malignancy) or freely
      mobile (i.e. moves up and down with swallowing)? If there is concern re: malignancy, a careful
      lymph node exam (described above) is important as this is the most common site of spread.

Lymph Nodes of the Head and Neck

                                              1. Anterior Cervical (both superficial and deep): Nodes
                                                 that lie both on top of and beneath the
                                                 sternocleidomastoid muscles (SCM) on either side of
                                                 the neck, from the angle of the jaw to the top of the
                                                 clavicle. This muscle allows the head to turn to the
                                                 right and left. The right SCM turns the head to the left
                                                 and vice versa. They can be easily identified by asking
                                                 the patient to turn their head into your hand while you
                                                 provide resistance. Drainage: The internal structures of
                                                 the throat as well as part of the posterior pharynx,
 Palpating Anterior Cervical Lymph               tonsils, and thyroid gland.

   2. Posterior Cervical: Extend in a line posterior to the SCMs but in front of the trapezius, from the
      level of the mastoid bone to the clavicle. Drainage: The skin on the back of the head. Also
      frequently enlarged during upper respiratory infections (e.g. mononucleosis).
   3. Tonsillar: Located just below the angle of the mandible. Drainage: The tonsilar and posterior
      pharyngeal regions.
   4. Sub-Mandibular: Along the underside of the jaw on either side. Drainage: The structures in the
      floor of the mouth.
   5. Sub-Mental: Just below the chin. Drainage: The teeth and intra-oral cavity.
   6. Supra-clavicular: In the hollow above the clavicle, just lateral to where it joins the sternum.
      Drainage: Part of the throacic cavity, abdomen.

                             Lymph nodes of the head and neck

A number of other lymph node groups exist. However, palpation of these areas is limited to those
situations when a problem is identified in that specific region (e.g. the pre-auricular nodes, located in
front of the ears, may become inflamed during infections of the external canal of the ear).

Infected lymph nodes tend to be:

      Firm, tender, enlarged and warm. Inflammation can spread to the overlying skin, causing it to
       appear reddened.

If an infection remains untreated, the center of the node may become necrotic, resulting in the
accumulation of fluid and debris within the structure. This is known as an abscess and feels a bit like a
tensely filled balloon or grape. Following infection, lymph nodes occasionally remain permanently
enlarged, though they should be non-tender, small (less the 1 cm), have a rubbery consistency and none
of the characteristics described above or below. It is common, for example, to find small, palpable nodes

in the submandibular/tonsilar region of otherwise healthy individuals. This likely represents sequelae of
past pharyngitis or dental infections.

Malignancies may also involve the lymph nodes, either primarily (e.g. lymphoma) or as a site of
metastasis. In either case, these nodes are generally:

      Firm, non-tender, matted (i.e. stuck to each other), fixed (i.e. not freely mobile but rather stuck
       down to underlying tissue), and increase in size over time.

                                                          Cervical Adenopathy: Right
                                                          anterior cervical adenopathy
                                                          secondary to metastatic
                  Cervical Adenopathy: Massive
                  right side cervical adenopathy
                  secondary to metastatic squamous
                  cell cancer originating
                  from this patient's oropharynx.

Several lymph nodes are located in the head and neck. Lymph nodes filter lymph, a clear substance
composed mostly of excess tissue fluid, after the lymphatic vessels collect it, but therefore it returns to
the vascular system. This filtering action removes bacteria and tumor cells from lymph. Lymphocytes
and antibodies are produced in the lymph nodes as a defense against invasion by foreign substances.
The most common head and neck lymph nodes are referred to as follows:
     Preauricular
     Postauricular
     Occipital
     Deep cervical

                                     Maxillary and Frontal Sinuses

   Drainage from various parts of the head and neck flows into a lymph node in the neck. When an
   enlarged lymph node is detected during assessment, the nurse needs to know from which part of the
   head or neck the lymph node receives drainage to assess whether an abnormality” infection.
   Disease” is in that area.

Examination for sinusitis should include the following:

   1. Examination of the nasal mucosa for colored discharge as described above. This is due to the fact
      that the maxillary sinuses drain into the nose via a passageway located under the middle
   2. Directly palpate and percuss the skin overlying the frontal and maxillary sinuses. Pain suggests
      underlying inflammation.
   3. Dim the room lights. Place the lighted otoscope directly on the infraorbital rim (bone just below
      the eye). Ask the patient to open their mouth and look for light glowing through the mucosa of
      the upper mouth. In the setting of inflammation, the maxillary sinus becomes fluid filled and will
      not allow this transillumination. There are specially designed transilluminators that may work
      better for this task, but are not readily available.

                               Transillumination of the right maxillary sinus

   4. Using a tongue depessor, tap on the teeth which sit in the floor of the maxillary sinus. This may
      cause discomfort if the sinus is inflamed.

   1. Ask the patient to flex the neck slightly forward to relax the sternomastoid muscles.
   2. Place the fingers of both hands on the patient’s neck so that your index fingers are just below the
      cricoid cartilage.
   3. Ask the patient to sip and swallow water as before. Feel for the thyroid isthmus rising up under
      your finger pads. It is often but not always palpable.
   4. Displace the trachea to the right with the fingers of the left hand; with the righthand fingers,
      palpate laterally for the right lobe of the thyroid in the space between the displaced trachea and
      the relaxed sternomastoid. Find the lateral margin. In similar fashion, examine the left lobe.
   5. The lobes are somewhat harder to feel than the isthmus, so practice is needed.
   6. The anterior surface of a lateral lobe is approximately the size of the distal phalanx of the thumb
      and feels somewhat rubbery.

7. Note the size, shape, and consistency of the gland and identify any nodules or tenderness.
8. If the thyroid gland is enlarged, listen over the lateral lobes with a stethoscope to detect a bruit, a
   sound similar to a cardiac murmur but of noncardiac origin.

Collecting Subjective Data

Nursing History
The following is a selection of questions you may ask and areas you cover with an average client.
   1. Have you noticed any lymph or lesions on your head and neck that do not heal or disappear?
   2. Do you have any difficulty moving your head or neck?
   3. Do you experience neck pain?
   4. Do you experience headache? Explain?
   5. Do you have any facial pain? Explain?
   6. Have you experienced any dizziness, lightheadedness, or loss of consciousness? Explain?

 Any lumps and lesions that do not heal or disappear may indicate cancer.
 Diseases and disorders involving head and neck muscles may limit mobility and affect daily
 Neck pain may accompany muscular problems or cervical spinal cord problems. Stress and
  tension may increase neck pain. Sudden head and neck pain seen with elevated temperature and
  neck stiffness may be a sign of meningeal irritation or inflammation.
 Older clients who have arthritis or osteoporosis may experience neck pain and a decreased range
  of motion.
 Description of the symptoms can help determine possible causes of the discomfort.
 Problems with the heart and neck vessels or neurologic system, such as carotid artery occlusion
  or inner ear disease, may cause dizziness.

Past History
   1. Describe any previous head and neck problems” trauma, injury” you have had? How were
       they treated? What were the results?
   2. Have you ever undergone radiation therapy for a problem in your neck region?

 Previous head and neck trauma may cause chronic pain and limitation of movement, and affect
 Radiation therapy has been linked to the development of thyroid cancer.

Family History
  1. Is there a history of head and neck cancer in your family?
  2. Is there a history of migraine headache in your family?

 Genetic predisposition is a risk factor for head and neck cancers.
 Migraine headache commonly have a familiar association.

Lifestyle and Health Practices

 1.   Do you smoke or chew tobacco? If yes, how much?
 2.   What is your typical posture when relaxing, during sleep, and when working?
 3.   In what kinds of recreational activity do you participate? Describe the activity?
 4.   Have any problems with your head or neck interfered with your relationships with others or the
      role you occupy at home or at work?

 Tobacco use increases the risk of head and neck cancer.
 Failure to use safety precautions increases the risk for head and neck injury.
 Poor posture or body alignment can lead to or exacerbate head and neck discomfort.
 Aggressive sports may increase the risk for a head and neck injury
 Head and neck pain may interfere with relationships or prevent client from completing their
  usual activities of daily living.

Collecting Objective Data

- Examining the head allows the nurse to evaluate the overlying protective structures before
evaluating the underlying special senses” vision, hearing, smell, and taste” and the functioning of the
neurologic system. This examination can detect head and facial shape abnormalities, asymmetry,
structural changes, or tenderness.
- Assessment of both the head and neck assists the nurse to detect enlarged or tender lymph nodes.