Chapter 7

Head and Neck

Equipment

• Tape measure

• Cup of water

• Stethoscope

• Transilluminator

EXAMINATION
Ask patient to sit.

Technique	Findings
Head and Face
Observe head position
	EXPECTED: Upright, midline, still.
	UNEXPECTED: Tilted, horizontal jerking or bobbing, tics, nodding.
Inspect facial features
• Shape Observe eyelids, eyebrows, palpebral fissures, nasolabial folds, mouth at rest, during movement, with expression.	EXPECTED: Variations according to race, sex, age, body build.
	UNEXPECTED: Change in shape. Unusual features: edema, puffiness, coarsened features, prominent eyes, hirsutism, lack of expression, excessive perspiration, pallor, or pigmentation variations.
• Symmetry Note if asymmetry affects all features of one side or a portion of face.	EXPECTED: Slight asymmetry.
	UNEXPECTED: Facial nerve weakness or paralysis, or problem with peripheral trigeminal nerve.
Inspect skull and scalp
• Size/shape/symmetry • Scalp condition • Systematically part hair from frontal to occipital region. • Hair pattern Pay special attention to areas behind ears, at hairline, at crown.	EXPECTED: Symmetric.
	UNEXPECTED: Lesions, scabs, tenderness, parasites, nits, scaliness.
	EXPECTED: Bitemporal recession or balding over crown in men.
	UNEXPECTED: Random areas of alopecia or alopecia totalis.
Palpate head and scalp
• Symmetry Palpate in gentle, rotary motion from front to back.	EXPECTED: Symmetric and smooth with bones indistinguishable. Ridge of sagittal fissure occasionally palpable.
	UNEXPECTED: Indentations or depressions.
Palpate hair
• Texture/color distribution	EXPECTED: Smooth, symmetrically distributed.
	UNEXPECTED: Splitting or cracked ends. Coarse, dry, or brittle. Fine and silky.
Palpate temporal arteries
Note course of arteries.	UNEXPECTED: Thickening, hardness, or tenderness.
Auscultate temporal arteries and over skull and eyes
	EXPECTED: No bruits.
Inspect salivary glands
• Symmetry/size Palpate if asymmetry noted. Have patient open mouth and press on salivary duct to attempt to express material.	UNEXPECTED: Asymmetry or enlargement. Tenderness. Discrete nodule.
Neck
Inspect neck
• Symmetry Inspect in usual position, in slight hyperextension, and during swallowing. Look for landmarks of anterior and posterior triangles.	EXPECTED: Bilateral symmetry of sternocleidomastoid and trapezius muscles.
	UNEXPECTED: Asymmetry, torticollis webbing, excessive posterior skinfolds, unusually short
	neck, distention of jugular vein; prominence of carotid arteries, or edema.
• Trachea Inspect in usual position, in slight hyperextension, and while patient swallows.	EXPECTED: Midline placement.
	UNEXPECTED: Masses.
Evaluate range of motion
Have patient flex, extend, rotate, laterally turn head and neck.	EXPECTED: Smooth.
	UNEXPECTED: Pain, dizziness, or limitation of motion.
Palpate neck
• Trachea Place thumb on each side of trachea in lower portion of neck, and compare space between trachea and sternocleidomastoid on each side.	EXPECTED: Midline position.
	UNEXPECTED: Deviation to right or left.
• Hyoid bone/thyroid and cricoid cartilages Have patient swallow.	EXPECTED: Smooth. Moves during swallowing.
	UNEXPECTED: Tender.
• Cartilaginous rings of trachea Have patient swallow.	EXPECTED: Distinct.
	UNEXPECTED: Tender.
• Tracheal tug With neck extended, palpate for movement with index finger and thumb on each side of trachea below thyroid isthmus.	UNEXPECTED: Tug synchronous with pulse.
Palpate lymph nodes
• Size/consistency, mobility/condition	UNEXPECTED: Enlarged, matted, tender, fixed, warm.
Palpate thyroid gland
• Symmetry Observe from frontal and lateral positions while patient hyperextends neck. Then observe as patient sips water while neck is hyperextended.	UNEXPECTED: Asymmetry. Enlarged and visible thyroid gland.
• Size/shape/configuration/consistency Stand either facing or behind patient. Have patient hold head slightly forward and tipped toward side being examined. Lightly palpate isthmus and lateral lobes. Give water to patient to facilitate swallowing. From the front, examine the left lobe by sitting on the left side of the patient and pressing the trachea to the left with the left thumb. Place the first three fingers in the thyroid bed just medial to the sternocleidomastoid. Keep your fingers still while the patient again swallows, thereby moving the gland beneath your fingers. Repeat on the right side. If gland is enlarged, auscultate for vascular sounds with stethoscope bell.	EXPECTED: Lobes small and smooth. Gland rises freely with swallowing. Right lobe as much as 25% larger than left. Tissue firm and pliable. UNEXPECTED: Enlarged, tender nodules (smooth or irregular, soft or hard); coarse tissue; gritty sensation. UNEXPECTED: Bruit.

AIDS TO DIFFERENTIAL DIAGNOSIS

Subjective Data	Objective Data
Myxedema
Cognitive impairment, slowed mentation, poor concentration, decreased short-term memory, social withdrawal, psychomotor retardation, depressed mood, and apathy.	Dull, puffy, yellow skin. Coarse, sparse hair. Temporal loss of eyebrows. Periorbital edema. Prominent tongue. Hypothyroidism (see table on p. 66).
Graves Disease
Symptoms of hyperthyroidism, palpitations, heat intolerance, weight loss, fatigue, increased appetite, tachycardia.	Diffuse thyroid enlargement, hyperthyroidism. Various pathologic conditions—ophthalmologic (prominent eyes, lid retraction, staring or startled expression), dermatologic (fine and moist skin, fine hair), musculoskeletal (muscle weakness), cardiac (tachycardia) (see table on p. 66).

Headaches

Characteristic	Classic Migraine	Medication Rebound	Cluster	Hypertensive	Muscular Tension	Temporal Arteritis	Space-Occupying Lesion
Headaches are one of the most common concerns and probably one of the most self-medicated. They are not always benign. A history of insistent headache that is severe and recurrent must always be given attention. Sometimes the underlying cause is life-threatening, such as a brain tumor. Sometimes it affects daily activities. The patient’s history is fully as important as the physical examination in getting at the root of a headache. Various kinds of headaches can be compared as follows:
Age at onset	Childhood		Adulthood	Adulthood	Adulthood	Older adulthood	Any
Location	Unilateral or generalized	Holocranial or diffuse	Unilateral	Bilateral or occipital	Unilateral or bilateral	Unilateral or bilateral	Localized
Duration	Hours to days	Hours	½ to 2 hours	Hours	Hours to days	Hours to days	Rapidly increasing frequency
Time of onset	Morning or night	Predictably begins within hours to days of the last dose of the medication	Night	Morning	Anytime, commonly in afternoon or evening	Anytime	Awakening from sleep
Quality of pain	Pulsating or throbbing	Dull or throbbing	Intense burning, boring, searing, knifelike	Throbbing	Bandlike, constricting	Throbbing
Prodromal event	Vague neurologic changes, personality change, fluid retention, appetite loss Well-defined neurologic event, scotoma, aphasia, hemianopsia, aura	Daily analgesic use	Personality changes, sleep disturbances	None	None	None	Aggravated by coughing or bending forward
Precipitating event	Menstrual period, missing meals, birth control pills, letdown after stress	Abrupt discontinuation of analgesics	Alcohol consumption	None	Stress, anger, bruxism	None	Develops in temporal relation to the neoplasm
Frequency	Twice a week	Gradual increase in headache frequency to daily	Several times nightly for several nights, then none	Daily	Daily	Daily	Progressive
Sex predilection	Females	Females	Males	Equal	Equal	Equal	Equal
Other symptoms	Nausea, vomiting	Alternate or preventive medications fail to control the headache	Increased lacrimation, nasal discharge	Generally remits as day progresses	None	None	Vomiting, confusion, abnormal neurologic findings, gait abnormality, papilledema, nystagmus

Hyperthyroidism versus Hypothyroidism

System or Structure Affected	Hyperthyroidism	Hypothyroidism
Constitutional
Temperature preference	Cool climate	Warm climate
Weight	Loss	Gain
Emotional state	Nervous, easily irritated, highly energetic	Lethargic, complacent, uninterested
Hair	Fine, with hair loss; failure to hold permanent wave	Coarse, with tendency to break
Skin	Warm, fine, hyperpigmentation at pressure points	Coarse, scaling, dry
Fingernails	Thin, with tendency to break; may show onycholysis	Thick
Eyes	Bilateral or unilateral proptosis, lid retraction, double vision	Puffiness in periorbital region
Neck	Goiter, change in shirt neck size, pain over thyroid	No goiter
Cardiac	Tachycardia, dysrhythmia, palpitations	No change noted
Gastrointestinal	Increased frequency of bowel movements; diarrhea rare	Constipation
Menstrual	Scant flow, amenorrhea	Menorrhagia
Neuromuscular	Increasing weakness, especially of proximal muscles	Lethargic, but good muscular strength

PEDIATRIC VARIATIONS
EXAMINATION

Technique	Findings
Head and Face
Palpate head and scalp
• Symmetry In infants, transilluminate skull	EXPECTED: An infant’s head circumference is 2 cm greater than chest circumference up to the age of 2 yr.
	UNEXPECTED: Ring of light greater than 2 cm with transillumination.
• Skull condition	EXPECTED: In infants, posterior fontanel closed at 2 mo; anterior fontanel closed at 12-15 mo.
	UNEXPECTED: Tenderness or depressions; sunken areas; swelling, bulging, or depressed fontanels.
• Scalp	EXPECTED: Free movement.
	UNEXPECTED: Fixation of scalp, bulging either on one side or crossing midline of scalp.
Percuss skull
	EXPECTED: Macewen sign, percussion near junction of frontal, temporal, and parietal bones producing a stronger resonant sound, is physiologic when fontanels are open.
	UNEXPECTED: Macewen sign may indicate hydrocephalus, a brain abscess is present, or increased intracranial pressure after fontanel closure.
Auscultate temporal arteries and over skull and eyes
	EXPECTED: Bruits are common in children up to age 5 yr.
Neck
Palpate thyroid gland
• Symmetry	EXPECTED: In children, thyroid gland may be palpable.
	UNEXPECTED: Tenderness.

Sample Documentation

Head

Held erect and midline. Skull normocephalic, symmetric, smooth without deformities. Facial features symmetric. Salivary glands not inflamed or tender. Temporal artery pulsations visible bilaterally, soft and nontender to palpation. No bruits.

Neck

Trachea midline. No jugular venous distention or carotid artery prominence. Thyroid palpable, firm, smooth, not enlarged. Thyroid and cartilages move with swallowing. No nodules or tenderness. No bruits. Full range of motion of neck without discomfort.