N209 - Head, Face, and Neck

Normocephalic

term that denotes a round, symmetrical skull that is appropriately related to body size

a,b,d

Which of the following would require you to further evaluate the pt. head, neck or face?

a. “any time I cough or sneeze, I get a headache.”

b. “I can’t turn my neck to the left side.”

c. “I don’t ever experience dizziness.”

d. “I had a concussion about a month ago.”

Normal = round, symmetric skull; appropriate size in relation to the body

Abnormal = large, fixed masses; inflammation of hair follicles (folliculitis); sebaceous cysts; pain, ulcers, indentations, old scars

Which of the following findings on the skull are abnormal and which are normal?

• round, symmetric skull

• large, fixed masses

• inflammation of hair follicles (folliculitis)

• appropriate size in relation to the body

• sebaceous cysts

• pain, ulcers, indentations, old scars

microcephaly

abnormally small head

macrocephaly

abnormally large head

Acromegaly

= large, elongated bones, jaw, forehead, nose, & lips

• possibly caused by a pituitary tumor bc of excessive secretion of GH

Hydrocephaly

= cerebrospinal fluid accumulation around the brain, causing the head to enlarge in babies

• Causes downcast or “sunsetting” eyes

• use shunts to drain fluid down brain to abdomen

temporomandibular joint

normal findings = smooth movement with no limitations and tenderness

abnormal findings = crepitation (crackling), tenderness, limited ROM

What is being palpated in the image? What is a normal finding? What is abnormal?

No, the face is asymmetrical.

Is this face a normal finding? why or why not?

Flat Facial Expression

fixed, nonmobile expression, shows no emotion

Labile

shifts rapidly b/t moods and facial expressions.

depressed or sad

withdrawn, turned down mouth, no eye contact

Eyebrows, palpebral fissures, nasolabial folds, sides of mouth

Where should you expect symmetry in the face?

Parkinsons Syndrome

= deficiency of the neurotransmitter dopamine and degeneration of the substantia nigra

• Immobility of features produces a face that is flat and expressionless

• Fixed/staring gaze, elevated eyebrows

Cachexia

= a wasting syndrome associated with complex disease processes such as cancer, heart failure, AIDS, and COPD

Signs:

• Severe weight loss

• Loss of muscle

• sunken eyes

• Hollow cheeks

• Fatigue

• Muscle weakness

• anorexia

Cushing Syndrome

Caused by excessive secretions of ACTH and chronic steroid use.

Signs:

• a rounded, “moonlike” face

• prominent jowls (lower portion of cheek)

• red cheeks

• hirsutism of upper lip

• lower cheeks & chin

• acneiform rash on chest

Bell’s Palsy

= a lower motor neuron lesion, producing rapid onset of cranial nerve VII paralysis of facial muscles

• almost always unilateral

• Most common cause of facial paralysis

Risk factors include:

• Being exposed to herpes simplex virus type 1

• Having diabetes

• Being pregnant

• Having had a previous episode of Bell's palsy

Stroke

= an upper motor neuron lesion; caused by a blood clot of a cerebral vessel

• lower face paralysis (can still move forehead and close eyes)

Fetal Alcohol Spectrum Disorder (FASD)

alcohol = a teratogenic to the developing fetus

• can cause intellectual disabilities, birth defects, & changes in face and brain structures

Signs:

• small, wide-set eyes

• wide flat area between eyes

• thin upper lip

• upturned nose

Myxedema

= a deficiency of thyroid hormone, meaning metabolic rate is reduced

• caused by hypothyroidism

Signs:

• dull skin

• round, swollen face and eyes

anterior triangle

Which triangle of the neck is this?

posterior triangle

Which triangle of the neck is this?

the nurse is in danger of cutting off both carotid arteries’ circulation to the brain

A nurse is palpating the neck on both sides at the same time. Why is this incorrect?

Torticollis

= a condition causing asymmetrical head or neck position (stiff neck, lateral flexion contracture)

Caused by:

• neck injury

• inflamed lymph glands

• sinus, ear, and throat infections

• tumors

• drug abuse (i.e., acetaminophens & cocaine)

Cranial Nerve XI (Accessory Nerve)

supplies the sternocleidomastoid and trapezius muscles

Holding hand on the side of the pt.’s face and have them push against your hand.

• note the sternocleidomastoid muscle contraction and any lymph/gland swelling.

Have the pt. shoulder shrug against resistance of your hand.

How would you test muscle strength and the status of cranial nerve XI?

lymph nodes

size, shape, borders, tenderness/pain, consistency should all be noted when palpating _________ _______.

b.

Which Size/shape indicates a normal lymph node?

a. large, irregular

b. <1 cm or nonpalpable, round

a.

Which delineation indicates an abnormal lymph node?

a. confluent

b. discrete

a

Which mobility indicates a normal lymph node?

a. mobile

b. fixed

b

Which consistency indicates a normal lymph node?

a. hard

b. soft

No, normal lymph nodes are non-tender

Would a tender node be a normal finding?

Preauricular

#1?

Posterior Auricular

#2?

Occipital

#3?

Submental

#4?

Submandibular

#5?

Jugulodigastric

#6?

Superficial Cervical

#7?

Deep Cervical Chain

#8?

Posterior Cervical

#9?

Supraclavicular

#10?

Lymphadenopathy

= enlargement of the lymph nodes (>1cm) from infection, allergy or neoplasm

The pt. has an acute infection

Lymph nodes are bilateral, enlarged, warm, tender, and firm, but are still freely moveable. What can this mean?

There is chronic inflammation (such as TB)

what does it mean if the lymph nodes are clumped together? What illness can cause this?

Cancer (CA)

If the lymph nodes are hard (like rocks), >3 cm, unilateral, nontender, and fixed, what can this indicate?

CA of the thorax or abdomen

What does a single, non-tender, hard, left supraclavicular node indicate?

Hodgkin Lymphoma (CA that affects the lymphatic system)

What do painless, rubbery, discrete nodes in the cervical region indicate?

HIV

What might the pt. have if their lymph nodes are enlarged, firm, non-tender, and mobile?

Occipital

Which nodes are common with HIV when abnormal?

with lung tumors, pneumothorax, or thyroid masses

When might the trachea be pushed to the unaffected/normal side?

lung diseases such as atelectasis (partial collapse of lung), plural adhesion, or fibrosis (thick lung tissue)

When might the trachea be pulled to the abnormal side?

pulled to the abnormal side

Is the trachea being pushed or pulled in the image?

pushed to the normal side

Is the trachea being pushed or pulled in the image?

tumor

What might unilateral bulging of the thyroid gland indicate?

Grave’s Disease (Hyperthyroidism)

= an autoimmune disease with increased production of TH and increased metabolic rate

manifested by:

• goiter

• bulging eyes

• eyelid retraction

posterior approach to assessing the thyroid gland

What does this photo depict?

nothing, the bell

What would you normally hear when listening to the thyroid gland? What part of the stethoscope is used?

Bruits

Soft, pulsatile, whooshing, blowing sound heard when there is accelerated or turbulent blood flow to the thyroid.

Pediatric variations

• unstable neck

• discrete, palpable nodes in children

• misshapen skulls from birth trauma

• measuring head circumference

Caput Succedaneum

swelling & ecchymosis from the presenting part of the head (resolves w/o treatment)

cephalhematoma

subperiosteal (beneath periosteum) hemorrhage (resolves w/o treatment)

craniosynostosis

premature closure of cranial sutures

• Results in malformed head & cosmetic deformity

• From genetic mutations

OA Variations

• Temporal artery may look prominent & twisted

• Isolated head tremors are benign (includes head nodding and tongue protrusion)

• Slower ROM head/neck

  • May experience dizziness

• Kyphosis (“hump back”)

• Thyroid often nodular and may be lower in the neck

  • Nearly impossible to palpate

Presyncope

= light-headed, swimming sensation from decreased blood flow to brain or decrease cardiac output

Vertigo

= room is spinning

Disequilibrium

= shakiness or instability when walking (r/t musculoskeletal disorder or multisensory deficits)

vagal stimulation or stimulation of carotid sinuses

palpation that can cause the heart rate to drop =

Thyroid Gland

usually nonpalpable, right side is 25% larger than left, sometimes felt in thin necks, and always felt in pregnancy.

migraine headache

quality: throbs, severe, recurs
duration: 3 or more days
location: eyes, temples, cheeks
S&S: nausea and vomiting, sensitive to light
relieving factors: rest, quiet, medications
gender: mostly women

cluster headache

quality: stabbing, intense
duration: transient evening, night
location: 1 eye, face, temples
S&S: tearing, red eye, runny nose
relieving factors: moving, pacing
gender: young males

tension headache

quality: dull, aches, tight
duration: months or days
location: frontal, temporal, occipital
S&S: anxiety, tension, heat, massage
relieving factors: medication
gender: more often women