Head and Neck

By O.Krekhovska-Lepyavko, MD, By O.Krekhovska-Lepyavko, MD,

Institute of Nursing, TSMUInstitute of Nursing, TSMU

Anatomy review

Anatomy

Anatomy – Salivary Glands

Anterior and Posterior Triangles

Anatomy

Lymphatics

Lymphatics

Anatomy - Lymphatics

History Headaches?

“Any unusually frequent or unusually severe headaches?”

A severe headache for a person who’s never had headaches should warrant further attention

When - onset, duration

Where Tension headaches – tend to be occipital or frontal Migraine headaches – supraorbital, retro orbital, or

frontotemporal Cluster headaches – pain around the eye, temple, forehead,

and cheek. Pain unilateral.

History

Character Throbbing (pounding, shooting) – migraine Aching (constant pressure, dull) – tension headache

Intensity - mild, moderate, or severe Precipitating factors Associated factors

Vision changes, N&V, pain with bright light, neck stiffness, fever,

Alleviating factors Other illnesses Medications

History Head injury?

When History of head injuries or other medical conditions? Location LOC – Loss of Consciousness?

Dizziness? Lightheadedness or spinning? Vertigo is true rotational spinning due to neurologic

dysfunction (vestibular apparatus) Objective – perception that room spins Subjective – perception that person is spinning

History

Neck pain? When, where, precipitating and alleviating factors

Acute onset of stiffness along with headache and fever occurs with meningeal inflammation

Limitations to ROM? Lumps or swelling?

Tenderness? Acute infection

Lumps If over 40, suspect malignancy until proven

otherwise Smoker? How long? Packs per day? Chew

tobacco? Increased risk of tumors

Assessment - Head Size and shape

Normocephalic Hydrocephalus

enlargement of head, increased circumference

Paget’s disease Enlargement and softening of

bone Acromegaly

abnormal enlargement of skull and facial bones

acromegaly

TMJ

Assessment - Head

Temporal artery Palpate above zygomatic bone,

between eye and top of ear Temporomandibular joint

Anterior of ear, between mandible and temporal bone

Palpate joint as person opens mouth. Normally smooth movement Abnormal – crepitations, limited ROM,

tenderness

Assessment - Face

Symmetry of eyebrows, mouth

Changes in skin Tics or twitches Tightened facial

muscles - pain

Stroke vs Bell’s Palsy

Bell’s Palsy CN VII paralysis Unilateral Thought to happen due

to herpes simplex virus Person cannot wrinkle

forehead, raise eyebrow, close eye, or show teeth on affected side

Stroke

Acute neurological deficit due to obstruction of cerebral vessel, as in atherosclerosis, or rupture in a cerebral vessel

Paralysis of lower facial muscles, but upper half of face not affected.

Still able to wrinkle forehead and close eyes

Fetal Alcohol Syndrome

Down Syndrome

Trisomy 21 Characteristics

Upslanting eyes Flat nasal bridge and

nose Protruding tongue Short broad neck with

webbing Small hands

Assessment - Neck Symmetry – head

and neck muscles ROM

Ask person to touch chin to chest, turn head to right and left, try to touch each ear to shoulder, extend head backwards

Note limitation of movement

Assessment - Neck

Muscle strength Test strength by resisting movement CN XI – Accessory n. – Trapezius m.

Thyroid gland Enlargement of lower neck may be

bilateral or a unilateral lump Diffuse enlargement or nodular lump

Palpating the Thyroid Gland Posterior approach Anterior approach

Place fingers inferior and lateral of thyroid cartilage and ask the person to swallow Usually, you cannot

palpate the normal adult thyroid

Enlarged lobes are also tender to palpation

Hypothyroidism Mild deficiency called

“hypothyroidism.” Severe deficiency called “myxedema.” In infancy called “cretinism.”

S/S: Face is pale, puffy, and

expressionless Skin is cold and dry Hair is brittle, hair loss Lowered heart rate and

temp Lethargy, fatigue,

intolerance to gold Impaired mentality Goiter!

Hypothyroidism

CauseHashimoto’s disease

Autoimmune disease where antithyroid antibodies block thyroid hormone production

Iodine deficiency in dietSurgical removal of thyroid

Hyperthyroidism

Grave’s disease Most common. More common in women. S/S

Rapid heartbeat, dysrhythmias, angina Rapid thought flow and rapid speech,

nervousness, and insomnia Increased BMR, appetite Goiter + Exophthalmos

Exophthalmos

Hyperthyroidism

Cause Thyroid Stimulating Immunoglobulins (TSIs)

mimic the effects of TSH on thyroid function

Toxic nodular goiter (Plummer’s disease) Result of thyroid adenoma Exophthalmos is missing

Lymph Nodes

Lymph nodes Beginning with the preauricular lymph nodes, palpate

the 10 groups of lymph nodes in a routine order Lymphadenopathy - enlargement of lymph nodes due to

infection, allergy, or neoplasm

Trachea Normally, the trachea is

midline Palpate for any tracheal

shift by placing index finger in the sternal notch Trachea pushed to unaffected side in aortic aneurism, a tumor, pneumothorax

Trachea pushed to affected side with large atelectasis, pleural adhesions, fibrosis

Tracheal tug is a rhythmic downward pull that is synchronous with systole and that occurs with aortic arch aneurysms

Developmental Considerations - Infants

Skull Should be round and

symmetrical Caput succedaneum –

elongation of skull at birth – resolves

Cephalohematoma – hemorrhage due to trauma at birth – resolves in few weeks (Fig 13-17)

Fontanels – anterior and posterior. Normally close by 2 years

Depressed – dehydration Bulging – increased ICP

Transillumination done if abnormal head size or intracranial lesion is suspected

Hydranencephaly – thinning or absence or cerebral cortex

cephalohematoma

transillumination

Assessment of Eyes and Ears

Eye Anatomy – Why Study It?

Why should you care?

Optometrist – Doctor of optometry, 4 year undergrad + 4 year optometry school

Ophthalmologists – Medical doctors In general, optometrists practice

primary and preventive eye care, while ophthalmologists perform eye surgery

What do nurses do?

History

Vision difficulty? Halos around lights – in glaucoma Scotoma – blind spot in visual field – in

glaucoma, optic nerve, and visual pathway disorder

Night blindness – Vit A deficiency, glaucoma,

Eye pain? Photophobia – inability to tolerate light

Childhood strabismus? A history of crossed eyes? AKA “lazy

eye” Redness or swelling?

Infections?

History cont.

Excessive or lack of tearing? May be due to irritants or obstruction in

drainage Past history of ocular problems? Glaucoma? Family history? Use of glasses or contact lenses? When tested last? Any medications?

Anatomy of Eyelid

Eyelids (L. palpebrae) protect the cornea and eyeball from injury

Canthi (sing. canthus) are corners of the eye, also called angles of eye

Caruncle is located near medial canthus and contains sebaceous glands

Tarsal plates are made of connective tissue and strengthen eyelid. They contain meibomian (tarsal) glands which secrete lipid to create airtight seal when closed and also prevent eyelids from sticking together

Inspecting External Ocular Structures

General Note if facial expression is relax or

tense Eyebrows

Note if movement is symmetrical Eyelids and lashes

Note if any redness, swelling, discharge or lesions

Note if eyelid closes completely and if drooping

Pallor of lower lid is good indicator of anemia

For upper eyelid, use applicator stick to fold the eyelid over

Abnormalities in Eyelids

Ectropion Lower lid rolls out, causing an

increase in tearing The eyes feel dry and itchy due

to inappropriate itching Increase risk for inflammation Occurs mostly in elderly due to

atrophy of elastic tissue

Entropion The lower lid rolls in Foreign body sensation

Abnormalities in Eyelids

Periorbital edema May occur with local

infection or systemic condition

Ptosis Occurs with

neuromuscular weakness (myasthenia gravis) or CN III damage

Lesions on the Eyelids

Blepharitis Inflammation of eyelids Staph or dermatitis Burning, itching, tearing,

foreign body sensation, pain

Chalazion A cyst in or an infection of

meibomian gland Nontender, firm, overlying

skin freely movable Hordeolum (Stye)

Localized Staph infection of hair follicle at lid margin

Painful, red, swollen, purulent

Anatomy of the Eye

Lacrimal apparatus provides irrigation of conjunctiva Lacrimal glands – secrete

lacrimal fluid (tears) Lacrimal ducts – lacrimal

fluid to conjunctiva Lacrimal canaliculi

(puncti) – drain fluid into Nasolacrimal duct –

conveys lacrimal fluid to nasal cavity

Inspecting the Lacrimal Apparatus

Inspect for bulges or pressure near canaliculi

Dacryocystitis Inflammation of the

lacrimal sac and/or nasolacrimal duct

Dacryoadenitis Infection of lacrimal

gland

DacryocystitisDacryoadenitis

Anatomy of Extraocular Muscles

4 rectus (straight) 2 oblique Innervations

SO4 – Superior oblique m.

CN IV (trochlear n.) LR6 – Lateral rectus m.

CN VI (abducens n.) AO3 – All other muscles

CN III ( Trigeminal n.)

Extraocular muscle movement

Extraocular Muscle Dysfunction

Anatomy of the Eyeball – Outer Layer

Sclera – tough protective white covering (posterior 5/6)

Cornea – transparent part of the fibrous coat covering the anterior of the eyeball (anterior 1/5)

Conjunctiva – transparent protective covering of exposed part of eye (palpebral conjunctiva covers inside of eyelash)

Corneal reflex – lightly touching the eye with cotton stimulates a blink.

Trigeminal n. (afferent) Facial n. (efferent)

iris

Inspection

Conjunctiva Sliding the lower lids down, observe

for redness on conjunctiva and if eyeball looks moist and glossy

Reddening may be pathogenic Sclera

Should be white, although may have gray-blue hue

Might contain yellowish fatty deposits beneath the lids

Yellowing of sclera indicates jaundice

Vascular Disorders of Eye

Conjunctivitis “Pink eye” Due to bacterial, viral, allergic, or

chemical irritation Redness throughout the conjunctiva,

but usually clear around the iris Purulent discharge usually common Symptoms: itching, burning, foreign

body sensation Iritis

Red halo around the iris and cornea Pupils may be irregular due to swelling Symptoms: photophobia, blurred

vision, throbbing pain

Inspecting Cornea and Lens

Corneal abrasion Assess by shining a light

and observing from the side

Pupillary light reflex Charted according to size

of pupil Charted as a ratio of

before light/after light (3/1)

A sluggish response may be caused by increased ICP

No response may indicate neurological damage

PERRLA:Pupils Equal, Round,React to Light and Accommodation

How to chart pupillary light reflex?

Anatomy of the Eyeball – Middle Layer

Choroid – provides vascularity to retina

Pupil – variable-sized, black circular or slit shaped opening in the center of the iris that regulates the amount of light that enters the eye. Appears black because most of the light entering the pupil is absorbed by the tissues inside the eye.

Lens – biconvex disc controlled by the ciliary muscle to produce far vision when flat

Anterior chamber Aqueous humor is produced by

the ciliary body and secreted into posterior chamber of eye.

From there, aqueous humor travels to the anterior chamber where it exits through the Canal of Schlemm

Determines intraocular pressure

Canal of Schlemm

Increase leads toGlaucoma

Vascular Disorders of Eye

Glaucoma Excessive pressure in

eye due to blockage of outflow from anterior chamber

This puts pressure on optic nerve

Redness around the iris, dilated pupils

Symptoms: sudden clouding of vision, sudden eye pain, and halos around lights

Physiology review:Aqueous humor is produced by the ciliary bodyand secreted into posterior chamber of eye. From there, aqueous humor travels to the anterior chamber where it exits through the Canal of Schlemm

Disorders of Opacity of Lens

Cataract

Anatomy of the Eyeball – Inner Layer

Retina – visually receptive layer where light waves are changed to nerve impulses

Optic disc – area where the optic nerve enters the eyeball

Fovea centralis – area of most acute vision

Inspecting the Ocular Fundus

Using an ophthalmoscope to inspect the internal surface of the retina, anterior chamber, lens, and vitreous.

Darken the room to dilate the pupils

Remove eye glasses, contacts may stay in

Ask person to stare at distant object

Hold ophthalmoscope close to your eye and move to within a few inches of the person’s face

A red glow filling the pupil is called the red reflex and is caused by light reflecting off the retina

Cataracts appear as opaque black areas against the red reflex

Inspecting the Optic Disc and Retina

Normal optic disc is: Yellow-orange to pink Round or oval Distinct margins

Normal retina is: Arteries in each

quadrant Arteries are bright red

Visual pathways

Testing Visual Reflexes

Pupillary light reflex Constriction of pupils when bright light shines on the retina Direct light reflex – constriction of same sided pupil Consensual light reflex – simultaneous constriction of both

pupils The impulse is carried afferently by CN II and efferently by

CN III Accommodation

Adaptation of eye for near vision Ask person to focus on distant object (dilates the pupils).

Then ask person to shift gaze to near object few inches away. A normal response is pupillary constriction and convergence of axes of the eyes

Testing Visual Accuity

Snellen Eye Chart Standing 20 feet from

the chart Test one eye at a time by

covering the other eye Leave contact lenses and

glasses on, unless the glasses are reading glasses

Normal vision is 20/20 Near vision

Use Jaeger card (smaller version of Snellen chart) or just read newspaper

Testing Visual Fields

Confrontation test Measures peripheral vision

compared to examiner (assuming examiner’s vision is normal)

Both examiner and pt cover one eye with a card, stand about 2 feet away, and maintain eye contact

Advance finger, starting from periphery, and ask patient to say “now” when the finger is first visible

Inability to see when the examiner sees suggests peripheral field loss

Testing Ocular Muscle Function

Cover Test Detects deviated alignment of eyes Ask pt. to stare straight at your nose

and cover one of the pt.’s eyes with a card

While noting the uncovered eye, move away the card

A normal response is a steady fixed gaze

Diagnostic Position Test Ask pt. to hold head straight and move

finger in all positions, holding it about 12 inches away

A normal response is parallel tracking of the objects with both eyes

Nystagmus Fine oscillating movements around the

iris Normal at extreme lateral gaze

Developmental Considerations – Infants and Children

Strabismus – must be detected and treated early to prevent permanent disability

Esotropia – inward turning of eye Exotropia – outward turning of

eye Color vision – due to inherited X-

linked recessive trait, occurs more often in boys

External eye structures – an upward lateral slope together with epicanthal folds occurs in Down syndrome

Ophthalmia neonatum – conjunctivitis due to bacteria, virus, or chemical irritation

Developmental Considerations – Aging

Decrease in visual acuity, diminished peripheral vision

Ectropion (drooping of lower lid) or entropion (eyelids turning in)

Pinguecula – yellow nodules due to thickening of conjunctiva as a result of prolonged exposure to sun, wind, and dust

Developmental Considerations - Aging

Arcus senilis – gray-white arc seen around the cornea. Due to deposition of lipids. No effect on vision

Xanthelasma – raised yellow plaques. Normal

Ear Anatomy

Ear Physiology

External Ear External auditory meatus funnels sound waves, which reflect

off the tympanic membrane to produce vibrations Cerumen (ear wax) protects the tympanic membrane from

foreign substances Middle ear

Malleus, incus, and stapes and eustachian tube Function to:

Conduct sound vibrations from tympanic membrane (outer ear) to cochlea (inner ear)

Protect the cochlea by reducing the amplitude of sounds Eustachian tube allows equalization of air pressure

Inner ear Vestibule and semicircular canals

Allow brain to sense body position and relation of angle of head to gravity

Cochlea Transfers vibrations from stapes into nerve impulses

The outer ear catches the waves of sound and funnels them down the ear canal (about an inch long) and flush up against the ear drum. The ear drum (tympanic membrane) is the boundary between the outer ear and the middle ear.

In the middle ear, the malleus picks up the vibrations from the eardrum, passes them to the incus which then passes them to the stapes. The stapes terminates in a tiny footplate that fits precisely into the contact point or window of the inner ear.

The window of the inner ear is the contact point of the cochlea. The vibrations set up rolling waves in the cochlear fluid which stimulate different areas of the membrane, which rubs against specialized cells called hair cells. This friction creates electrical impulses transmitted by the cochlear nerve.

CN VIII is responsible for signal transduction from vestibule and cochlea to the brainstem. From brainstem, a signal is sent to the cerebral cortex to interpret the sound.

Hearing Loss

Conductive Mechanical dysfunction of external or middle ear Partial hearing loss May be caused by impacted cerumen, foreign

bodies, perforated tympanic membrane, pus or serum in middle ear, or otosclerosis (hardening of stapes)

May be fixed Sensorineural

Dysfunction of inner ear, CN VIII, or cerebral cortex Cannot be fixed

Developmental Considerations Infants

Greater risk for otitis media (middle ear infections) due to shorter eustachian tube

Aging Cilia lining ear canal become coarse and stiff, impeding sound

waves Cerumen more common

Dry cerumen – gray and flaky. More common in Asians and Native Americans

Wet cerumen – brown and moist. More common in whites and blacks

Presbycusis - degenerative sensorineural hearing loss Auditory reaction time increases

Obtaining History

Earaches? (otalgia) Location, character, intensity, associative and alleviating factors May be directly due to ear disease or maybe referred pain from

a problem in teeth or oropharynx A viral or bacterial upper respiratory infection may migrate up the

eustachian tube and involve the middle ear

Infections? Frequency? Occurred in childhood?

Discharge? (otorrhea) May suggest infection or perforated eardrum Typically with perforation, ear pain drainage

Otitis externa – purulent, sanguineous, or watery Acute otitis media with perforation – purulent discharge

More History

Trouble hearing? Gradual our sudden?

Presbycusis – gradual sensorineural hearing impairment in the elderly

Hearing loss due to trauma is often sudden Ringing in ears? (tinnitus)

May be a result of medication Medications?

Some are ototoxic Vertigo? (spinning)

Subjective – person feels like he or she spins Objective – person feels like room spins

Environmental noise Noise-induced hearing loss

Lesions of External Ear

Gouty Tophi

Otitis Externa

Assessing External Ear

Size and Shape normal is 4-10cm tall

Skin conditions Note edema, inflammation, lesions

Tenderness Location?

Pain in pinna indicates otitis externa Pain at mastoid process indicates mastoiditis or

lymphadenitis External Auditory Meatus

Atresia – absence or closure of ear canal Otitis externa may cause purulent discharge Otitis media may cause rupture of tympanic membrane If drainage present following trauma, possible basal skull

fracture. Perform glucose test (CSF (+) for glucose).

Inspecting Using Otoscope

Pull the pinna up and back in adult, straight down in children under 3 years

Hold otoscope upside down and place dorsal side of hand along person’s cheek

Insert speculum slowly and avoid touching the inner section of canal wall, which is sensitive and may cause pain.

Inspecting the External Canal

Note any redness or swelling, lesions, or foreign bodies

If discharge present, note color and odor

OtitisExterna

Inspecting the Tympanic Membrane

Normal is shiny and translucent

Flat, slightly pulled in at the center Valsalva maneuver

causes tympanic membrane to flutter, used to assess drum mobility

Which tympanic membraneis perforated?

Testing Hearing Acuity

Voice test Whisper two syllable

words into one of the person’s ears, while covering the other one. Ask person to repeat what you’ve said.

Tuning fork tests Measure hearing by air

conduction or bone conduction

Weber test Rinne test

Weber Test

Tuning fork is struck and placed on head or forehead, equal distance from both ears

Used to determine if hearing loss is more extensive in one ear than the other

This test cannot confirm normal hearing, because hearing defects affecting both ears equally will produce an apparently normal test result

Rinne Test

Compares air conduction and bone conduction

Place stem of vibrating fork on mastoid process and ask when sound goes away

Quickly invert the fork so the vibrating end is near the ear canal. The person should still hear a sound

Normally the sound is heard longer by air conduction rather than bone conduction

In conductive hearing loss, sound heard longer by bone conduction

Normal Hearing

Conductive Hearing Loss

Sensorineural Hearing Loss

Infants and Children Save otoscopic examination until the end May help to show otoscope to child and let

him or her play with it Stabilize (or ask a parent for help) the

child’s head in order to prevent movement Pull pinna straight down In infants, the tympanic membrane may

look thick and opaque after first few days or after crying

Tympanostomy tubes may be in place if drainage occurs as a result of otitis media

Abnormalities in the Ear Canal

Excessive Cerumen

Acute Otitis Media

Otitis Externa