Health Assessment

Week 8
Head, Neck, Face and Lymphatics
Chapter 14

The Head
The skull is a bony box that protects the brain and special sense organs and included the bones
of the cranium and face.
Cranial bones: frontal, parietal, occipital, temporal bones are formed together/articulate by
immovable joints called sutures
Coronal suture: crowns the head, connects frontal and parietal
Sagittal suture: separates lengthwise the two parietal bones
Lambdoid suture: separates crosswise the occipital and parietal bones
Palpebral fissures: openings between the eyelids

Cranium is supported by C1 (atlas), C2 (axis) to C7 vertebrae

Facial Nerves
Facial expressions are mediated by cranial nerve VII (7) the facial nerve. Facial muscles general
move symmetrically bilaterally, unless it’s a smirk of wry expression. Damage to this nerve can
cause marked facial asymmetry.
Facial sensations are mediated by three sensory branches of cranial nerve V (5) the trigeminal
nerve.

Salivary glands
Parotid glands: in the cheeks, anterior to and below the ears. Largest of the salivary glands but
usually not palpable.
Submandibular glands: beneath the mandible at the angle of the jaw.
Sublingual glands: on the floor of the mouth, under the tongue

Temporal artery: Anterior to the ear, superior to the temporalis muscle

The Neck
The passageway for many structures: vessels, muscles, nerves, lymphatic vessels, viscera of the
respiratory system and digestive system. Major Blood vessels: carotid (supplies blood to the
face, salivary glands and superficial temporal area) and jugular arteries.

Major muscles: innervated by cranial nerve XI (11) the spinal nerve. Sternomastoid and the
trapezius.
Sternomastoid – arises from the sternum and the medial part of the clavicle, extends diagonally
across the neck to the mastoid process behind the ear. Accomplishes head rotation and head
flexion.
Trapezius – two muscles form a trapezoid on the upper back. Each arises from the occipital
bone and the vertebrae and fans out to the scapula and clavicle. Moves shoulders and
extend/turn the head.
Thyroid Gland
Endocrine gland with a rich blood supply. Straddles the trachea in the middle of the neck.
Synthesizes and secretes thyroxine (T4) and triiodothyronine (T3) that stimulate the rate of
cellular metabolism.

Lymphatic System
The head and neck have the most abundant lymphatic supply.
 Preauricular: in front of the ear
 Posterior auricular (mastoid): superficial to the mastoid process
 Occipital: at the base of the skull
 Submental: midline, behind the tip of the mandible
 Submandibular: halfway between the angle and the tip of the mandible
 Tonsillar: under the angle of the mandible
 Superficial cervical: overlying the sternomastoid muscle
 Deep cervical: deep under the sternomastoid muscle
 Posterior cervical: in the posterior triangle along the edge of the trapezius muscle
 Supraclavicular: just above and behind the clavicle, at the sternomastoid muscle
Lymph nodes are found in the head and neck, the arms, the axillae, and the inguinal region.
When lymph nodes are enlarged, look for problems in the area proximal (upstream) from
where they drain.

Developmental Considerations
Pregnant women: thyroid enlarges during pregnancy as a result of hyperplasia (increased cell
production) and increased vascularity.
Older adults: facial bones and orbits are more prominent, facial skin sags, lower face will
appear smaller if teeth are lost.

Normal Findings
HEAD
Normocephalic – round, symmetrical skull, appropriate size in relation to body.
Microcephaly – abnormally small head
Macrocephaly – abnormally large head caused by hydrocephaly (obstruction of the drainage of
cerebrospinal fluid from the skull) or acromegaly (enlarged skull and thickened cranial bones)

The skull should feel symmetrical and smooth, no lumps or bumps. There are normal
protrusions on the forehead, the lateral edge of each parietal bone, the occipital bones and the
mastoid process behind each ear.
Temporal area should be palpable above the zygomatic (cheek) bone between the eyes and the
top of the ear.
Temporal arteritis – the artery looks tortuous and feels hardened and tender

Temporomandibular joint is below the temporal artery and anterior to the tragus, have patient
open and close mouth slowly, should be smooth with no limitations of tenderness.
Abnormalities include crepitation, limited ROM and tenderness.

Facial structures should be symmetrical and consistent. Marked asymmetry can be causes by a
central brain lesion (e.g., cerebrovascular accident) or with peripheral damage to cranial nerve
VII (Bell’s Palsy).

NECK
Head position is centred in the midline, accessory neck muscles are symmetrical. Head should
be erect and still.
Range of motion shouldn’t be limited. Ask patient to touch their chin to the chest, ears to
shoulders (without elevating shoulders), neck back towards spine. Movements should be
smooth.
Test cranial nerve XI by trying to resists the patient’s movements with your hands as the
patient shrugs and turns head to the side. As patient turns head, note any enlargement of
salivary glands of lymphatic nodes.

Lymph nodes should be palpated gently. In mumps and AIDS, the parotid glands are swollen.
Lymphadenopathy is the enlargement of lymph nodes >1cm caused by infection, allergy or
neoplasm (abnormal growth of cells/tumor).
Acute infection: nodes are bilaterally enlarged, warm, tender and firm but freely movable.
Chronic inflammation: nodes are clumped.
Cancerous nodes: nodes are hard, unilateral, nontender and fixed.
HIV infection: nodes are enlarged, firm, nontender and mobile. Occipital node enlargement is
common.
Neoplasm in the thorax/abdomen: a single left node may be enlarged, nontender and hard
(Virchow’s Node).
Hodgkin’s Lymphoma: discrete nodes that are painless and rubbery gradually appear.

Trachea should be midline, palpate for any tracheal shift. Space on both sides of the trachea
should be equal.
Trachea may be pushed to the unaffected/healthy side in the presence of an aortic aneurysm,
a tumor, unilateral thyroid lobe enlargement and pneumothorax (collapsed lung).
The trachea is pulled toward the affected side with large atelectasis (complete lung collapse),
pleural adhesions or fibrosis.
Tracheal tug is the rhythmic downward pull that is synchronous with systole and that occur
with an aortic arch aneurysm.
Thyroid gland is hard to palpate. Ask patient to tilt head back and swallow. Assess for any
bulges.
If the thyroid gland is enlarged, auscultate for bruits (soft, pulsatile, whooshing/blowing sound
heard with the bell of the stethoscope), they shouldn’t be present.

Grave’s Disease
Most common cause of hypothyroidism (myxedema).
Signs and symptoms:
 Exophthalmos (bulging eyes)
 Goiter (thickened neck)
 Fatigue
 Weight loss
 Nervousness

Senile tremors – benign and include head nodding and tongue protrusion. In some older adults,
a mild rhythmic tremor of the head may be normal.

Post-concussion syndrome
 Headache
 Dizziness
 Feeling dazed
 “Seeing stars”
 Sensitivity to light
 Ringing ears
 Tiredness
 Nausea
 Vomiting
 Irritability
 Confusion
 Disorientation
Most concussions occur WITHOUT loss of consciousness.