Head and Neck
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





Intensity - mild, moderate, or severe
Precipitating factors
Associated factors




Throbbing (pounding, shooting) – migraine
Aching (constant pressure, dull) – tension headache
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?


Lumps


Acute infection
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
 Cause

Hashimoto’s disease

Autoimmune disease where antithyroid
antibodies block thyroid hormone
production
Iodine deficiency in diet
 Surgical removal of thyroid

Hyperthyroidism

Grave’s disease


Exophthalmos
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
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
transillumination
cephalohematoma
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?




Eye pain?


Photophobia – inability to tolerate light
Childhood strabismus?


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,
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


Eyebrows


Note if facial expression is relax or
tense
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




Chalazion



Inflammation of eyelids
Staph or dermatitis
Burning, itching, tearing,
foreign body sensation,
pain
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
Dacryoadenitis
Dacryocystitis
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)
iris
Corneal reflex – lightly touching the eye with cotton
stimulates a blink.
Trigeminal n. (afferent)
Facial n. (efferent)
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
How to chart
pupillary light reflex?
PERRLA:
Pupils Equal, Round,
React to Light and
Accommodation
Anatomy of the Eyeball –
Middle Layer




Canal of Schlemm
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
Increase leads to
Glaucoma
Vascular Disorders of Eye
Physiology review:
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

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
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
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


Infections?


A viral or bacterial upper respiratory infection may migrate
up the eustachian tube and involve the middle ear
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?



Ringing in ears? (tinnitus)


Some are ototoxic
Vertigo? (spinning)



May be a result of medication
Medications?


Presbycusis – gradual sensorineural hearing
impairment in the elderly
Hearing loss due to trauma is often sudden
Subjective – person feels like he or she spins
Objective – person feels like room spins
Environmental noise

Noise-induced hearing loss
Lesions of External Ear
Otitis Externa
Gouty Tophi
Assessing External Ear

Size and Shape


Skin conditions


normal is 4-10cm tall
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
Otitis
Externa
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 membrane
is 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
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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
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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
Normal Hearing
Conductive Hearing Loss
Sensorineural Hearing Loss
Infants and Children
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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
Acute Otitis
Media
Otitis Externa
Excessive Cerumen