HEAD AND NECK REGIONAL LYMPHATICS

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HEAD AND NECKREGIONAL LYMPHATICS
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LEARNING OBJECTIVE ONE

• Anatomy and Physiology Review

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LEARNING OBJECTIVE ONE

• Head
• Skull
• Cranium and face
• Cranial bones
• Frontal
• Parietal
• Temporal
• Occipital

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The Head

• Skull a bony box protects the brain special
  sense organs.
• Cranial bones frontal, parietal, occipital,
  temporal

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Sutures

• immovable joints coronal crowns head from ear
  to ear at the union of the frontal parietal
  bones, sagittal separate head lengthwise between
  two parietal bones. lambdoid suture separates
  parietal bones from occipital bone.

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FONTANELS(fontenelle little fountain)

• At birth, membrane-covered soft spots between
  cranial bones
• These soft spots will eventually ossify-replaced
  by bone
• Allow for growth of the brain during the first
  year
• Posterior or occipital will ossify by 2 months
• Anterior or frontal will ossify by 18-24 months

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LEARNING OBJECTIVE ONE

• Head
• Facial bones
• Facial muscles
• Expression of emotion
• Neck movement
• Controlled by cranial nerves V and VII

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FACIAL BONES

• 14 Facial Bones articulate at sutures except for
  the mandible
• NASAL-forms part of bridge of nose
• PAIRED MAXILLAE- Unite to form upper jaw bone
• ZYGOMATIC- Commonly called cheekbones
• MANDIBLE- Lower jawbone largest, strongest
  facial bone only skull bone that moves
• LACRIMAL- Smallest bones in face lateral to
  nasal bones

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FACIAL MUSCLES

• Facial expressions are formed by the facial
  muscles
• Mediated by cranial nerve VII, the facial nerve
• Facial muscle is symmetrical bilaterally, except
  for an occasional quirk or wry expression

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Figure 13-2 pg 273
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LEARNING OBJECTIVE

• Neck
• Carotid and temporal arteries
• Supported by vertebra and muscles
• Neck muscles
• Anterior and posterior triangles
• Hyoid bone
• Thyroid gland

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The Neck

• from base of the skull to manibrium, clavicle,
  1st rib,1st thoracic vertebra below.
• Structures are vessels, muscles, nerves,
  lymphatics viscera of the respiratory and
  digestive system.
• Carotid artery, jugular vein(internal
  external).

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NECK VESSELS

• TEMPORAL ARTERY-Lies superior to the temporalis
  muscle, and its pulsation is palpable anterior to
  the ear
• CAROTID ARTERY-Right and left arise from the
  aorta and are the principal blood supply to the
  head and neck each of these two arteries divide
  to form the external and internal carotid arteries

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NECK VESSELS
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NECK VESSELS

• JUGULAR VEIN- External-Lies superficial to the
• sternocleidomastoid muscle as it passes down the
  neck to
• join the subclavian vein receives blood from
  the exterior
• of the cranium and the deep parts of the face
• INTERNAL-
• Directly continuous with the transverse sinus,
• accompanying the internal carotid as it passes
  down the
• neck Receives blood from the brain and
  superficial parts
• of the face and neck

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NECK MUSCLES

• STERNOMASTOID- Arises from the sternum and the
  medial part of the clavicle and extends
  diagonally across the neck to the mastoid process
  behind the ear Accomplishes head rotation and
  flexion
• TRAPEZIUS- Two muscles that form a trapezoid
  shape on the upper back arising from the
  occipital bone and extends fanning out to the
  clavicle and scapula moves the shoulders and
  extends and turns the head

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Muscles

• sternomastoid ( head rotation head flexion)
  trapezius( moves shoulders extend turn head).

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MUSCLES OF THE NECK

• Muscles of the Neck

Figure 13-4. p 274.
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LANDMARKS

• Vertebra Prominens-C7 vertebra has a long
  spinous process that can be felt when the neck is
  flexed
• Temporal Artery-Pulsation is palpable anterior to
  ear

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Thyroid gland

• in the middle of the neck, has 2 lobes, separated
  by isthmus, secrete T3T4 hormones(stimulate
  metabolism)

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Cricoid cartilage

• above thyroid isthmus, thyroid cartilage above
  that(adams apple) in males, highest is hyoid
  bone.

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The Lymphatic's

• 1.    preauricular in front of ear
• 2.    posterior auricular superficial to mastoid
  process
• 3.    occipital at the base of the skull
• 4.    submental midline
• 5.    submandibular halfway between the angle
  tip of the mandible.

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The Lymphatic's

• 6.    superficial cervical overlying
  sternomastoid muscle
• 7.    deep cervical under sternomastoid muscle
• 8.    posterior cervical at the edge of the
  trapezius
• 9.    supraclavicular above clavicle, at
  sternomastoid

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• THANK YOU

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LEARNING OBJECTIVE TWO

• Focused Interview
• General questions

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Subjective Data

• 1.   Headache
• onset- when did this kind of headache start?
•   Location- where do you feel it?
• Is pain localized on one side or all over?
• Character throbbing(shooting) or aching (dull)?
• Is it mild, moderate, or sever?
• Duration- what time of day do the headaches
  occur morning, evening?

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1.   Headache cont

• How long do they last?
• Precipitating factors- what brings it on?
• Associated factors- as nausea or vomiting?
• Do you have any other illness?
• Do you take any medications?

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Types of headaches

• Headaches
• Migraine
• Cluster
• Tension

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2.   Head injury

• onset-when? describe exactly what happened?
• Setting- any hazardous conditions as(wearing
  helmet)?
• Any hx of illness as DM?
• Duration- how long were you unconscious?
• Associated symptoms- as vision change?

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3. Dizziness

• onset- abrupt or gradual? Associated factors? As
  nausea or vomiting or tinnitus
• 4. Neck Pain
• onset- how did the pain start? injury
  accidentetc
• location- does the pain radiate? to shoulder,
  arms?
• Associated symptoms- limitations to range of
  motion
• Precipitating factors-what movements cause pain?

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6.   Lumps or swelling

• how long have you had it? has it changed in
  size?
• Any difficulty swallowing?
• Do you smoke?
• Ever had a thyroid problem?
• 7.    history of head or neck surgery
• for what condition? when did the surgery
  occur?     

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• Specific Questions
• Illness, infection, or injury
• Symptoms
• Pain
• Behaviors
• Infants and children
• Environment

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• THANK YOU

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Objective Data

• The Head

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LEARNING OBJECTIVE THREE

• Assessment of the Head and Neck
• Techniques
• Inspection
• Palpation
• Auscultation

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LEARNING OBJECTIVE THREE

• Areas of the Head
• Palpation of the head and scalp
• Observation of the skin and tissue integrity
• Palpation of the temporal artery

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Areas of the Head

• Inspection and palpate of the head and scalp
• Inspection and palpate of the face
• Observation of movements of the head, face, and
  eyes

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INSPECT PALPATE SKULL

• 1- size shape Normocephalic, round symmetric
  skull, related to body size. for shape palpate
  scalp, no tenderness(symmetric smooth).
• 2- temporal area palpate temporal artery,
  palpate joint tempomandibular joint- as the
  person opens mouth, no limitation or tenderness.

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Figure 12.10 Palpating the temporal artery.
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Abnormalities of the Skull and Face
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Hydrocephalus
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Acromegaly
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Down syndrome
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INSPECT THE FACE

• facial structures facial expression appropriate
  to behavior CN VII , symmetric same for eye
  brows, nasolabial folds sides of the mouth.
  note any involuntary movements.

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Abnormal Facial Features

• TICS- Abnormal facial movements
• Exophthalmos- bulging eyeballs
• Acromegaly- Gradual enlargement of the bones of
  the face and jaws

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Abnormalities of the Skull and FaceParalysis
following brain attack
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Abnormalities of the Face Bells palsy
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 The Neck

• INSPECT PALPATE THE NECK

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NECK

• Symmetry head held erect still
• ROM ask the person to touch the chin to chest,
  turn head to rt lt, try to touch each ear to
  the shoulder- test muscle strength ( cranial
  nerve XI) by trying to resist the persons
  movements with your hands as the person shrugs
  shoulders turns the head to each side.- note
  enlargement of salivary glands lymph nodes-
  note pulsations(carotid artery)

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• Trachea midline, palpate for shift, place your
  index on trachea in the sternal notch slip it
  off to each side. Should be symmetric on both
  sides.

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Palpate Trachea

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Thyroid gland

• inspect neck as person takes a sip swallow ,
  thyroid moves up with a swallow
• a. posterior approach move behind the person ask
  him to sit up straight then to bend head
  slightly forward to right, use fingers of your
  lt hand to push trachea slightly to rt. Curve
  your rt fingers between trachea sternomastoid ,
  ask him to take a sip of water ,thyroid moves up,
  reverse the procedure for lt side, check for
  enlargement, symmetry.

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Thyroid gland

• Posterior approach

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Palpate Thyroid Posterior appraoch
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Thyroid gland

• b. anterior approach stand facing person. ask
  him to tip head forward to rt, use your rt
  thumb to displace trachea slightly to the
  persons right. Hook your lt thumb fingers
  around the sternomastoid. Feel for lobe
  enlargement as he swallows.
• c. auscultate thyroid if it enlarged auscultate
  for bruit( a soft pulsatile blowing sound heard
  with bell).

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Thyroid gland

• Anterior approach

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Palpate Thyroid Anterior appraoch

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NECK cont

• Lymph nodes using gentle circular motion of your
  finger pads, palpate lymph nodes, palpate 10
  groups in a routine order in both hands. if any
  nodes are palpable note location, size, shape,
  mobility, tenderness, cervical nodes palpable in
  health persons decreased with age, normal nodes
  feel movable, soft no tender.

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Palpating Lymph Nodes

• USE A FIRM DELIBERATE YET GENTLE TOUCH
• INFECTION- May be indicated when nodes are
  palpable bilaterally, feel large, warm, tender,
  firm but freely movable
• MALIGNANCY- May be indicated when nodes are
  unilateral, hard, discrete, asymmetric, fixed,
  and no tender
• Abnormal Nodes- Explore the area proximal
  (upstream) to the location of the abnormal node

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Palpate Deep Cervical Chain

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Palpate supraclavicular node

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Palpate cervical nodes

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• THANK YOU

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Clinical Case Study 1

• Focused Assessment

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• Mr. Omar A. is a 57-years old ,insurance
  executive who is in his fourth postoperative day
  after a transurethral resection of the prostate
  gland. He also has chronic hypertension, managed
  by oral hydrochlorothiazide, exercise, and a
  low-salt diet.

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Subjective data

• Complaining of dizziness, a lightheaded feeling
  that occurred on standing and cleared on sitting.
  No previous episodes of dizziness. Denies
  palpitations, nausea, or vomiting. States urine
  pink tinged as it was yesterday with no red
  blood. No pain medication today. On second day
  of same antihypertensive medication he took
  before surgery.

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Objective data

• BP 142/88 RA sitting, 94/58 RA standing. Pulse 94
  sitting and standing, regular rhythm, no skipped
  beats. Temp 37o C.
• Color tannish-pink, no pallor, skin warm and dry.
• Neuro Alert and oriented to person, place, and
  time. Speech clear and fluent. Moving all
  extremities, no weakness. No nystagmus, no
  ataxia, past pointing normal. Rombergs sign
  negative (normal). Intake/output in balance.
  Urine faint pink tinged, no clots.
• Lab Hct 45, serum chemistries normal.

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Assessment

• Orthostatic hypotension
• Risk for injury R/T orthostatic hypotension

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Clinical Case Study 2

• Focused Assessment
• Mara is a 19-year-old single white female college
  student with a history of good health and no
  chronic illnesses she enters the outpatient
  clinic today stating. I think Ive had a
  stroke.

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Subjective data

• One day PTA first noticed at dinner at college
  cafeteria when joking with friends, started to
  stick out tongue and roll tongue and could not do
  it, right side of tongue was not working. Mara
  left room to look in mirror and became scared
  when smiled, noticed right side was not working.
  Tried to pucker lips, could not. Could not
  whistle, could not raise eyebrow

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• I looked like a Vulcan. No other movement
  disorder below neck. Mild pain behind right ear
  with buzzing in ear. Able to sleep last night,
  but roommate said Maras right eyelid did not
  close completely during sleep.
• Today still no movement on complete right side
  of face. Feeding self-conscious in class and
  during conversations with friends. Now has taste
  aversion, fluids with high water content taste
  especially bitter. No hearing loss.

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Objective data

• T 37o C, P 64, R 14, B/P 108/78
• Forehead appears smooth and immobile on right,
  unable to wrinkle right side. Unable to close
  right eye, Bells phenomenon present when
  attempts to close (right eyeball rolls upward),
  right plapebral fissure appears wider. No corneal
  reflex on right. Unable to whistle or puff right
  cheek. Absent nasolabial fold on right. Mouth
  sroops on right, sags

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Objective data

• on right when tries to smile. Slight drooling.
  Left side of face responds appropriately to all
  these movements. Superficial sensation intact.
• Rest of musculoskeletal system intact able to
  hold balance while standing, able to walk
  heel-to-toe, do knee bend on each knee. Arm
  strength and range of motion intact.

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Assessment

• Right-sided facial paralysis, consistent with
  Bells palsy
• Disturbed body image R/T effects of loss of
  facial function
• Risk for deficient fluid volume R/T taste
  aversion and dietary alteration
• Risk for sensory deficit, visual Impairment, R/T
  effects of neurological impairment

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