PHYSICAL ASSESSMENT: HEAD

AND NECK
BY: Rhodeva Joy T. Braga, RN, USRN
• Head and neck assessment focuses on
the cranium, face, thyroid gland, and
lymph node structures contained within the
head and neck.
ANATOMY
 CRANIUM
• The cranium houses and protects the brain and
major sensory organs. It consists of eight bones:
– Frontal (1)
– Parietal (2)
– Temporal (2)
– Occipital (1)
– Ethmoid (1)
– Sphenoid (1)
• In the adult client, the cranial bones are joined together
by immovable sutures: the sagittal, coronal, squamosal,
and lambdoid sutures.
 FACE
• Facial bones give shape to the face. The face
consists of 14 bones:
– Maxilla (2)
– Zygomatic (cheek) (2)
– Inferior conchae (2)
– Nasal (2)
– Lacrimal (2)
– Palatine (2)
– Vomer (1)
– Mandible (jaw) (1)
 FACE
• All of the facial bones are immovable
except for the mandible.
• The parotid glands are located on each
side of the face, anterior and inferior to the
ears and behind the mandible.
• The submandibular glands are located
inferior to the mandible, underneath the
base of the tongue.
 NECK
• The structure of the neck is composed of
muscles, ligaments, and the cervical
vertebrae Contained within the neck are
the hyoid bone, several major blood
vessels, the larynx, trachea, and the
thyroid gland, which is in the anterior
triangle of the neck
 LYMPH NODES OF THE HEAD AND NECK

• Lymph nodes filter lymph, a clear substance

composed mostly of excess tissue fluid, after
the lymphatic vessels collect it but before it
returns to the vascular system
• The size and shape of lymph nodes vary but
most are less than 1 cm long and are buried
deep in the connective tissue, which makes
them nonpalpable in normal situations. They
usually appear in clusters that vary in size
from 2 to 100 individual nodes.
 CULTURAL CONSIDERATIONS
• Take care to consider cultural norms for touch
when assessing the head. Some cultures
(e.g., Southeast Asian) prohibit touching the
head or touching the feet before touching the
head (Purnell & Paulanka, 2003).
• Another important thing to keep in mind as
you examine the head and neck is that
normal facial structures and features tend to
vary widely among individuals and cultures.
 EQUIPMENT

• Gloves
• Small cup of water
• Stethoscope
 SPECIAL CONSIDERATION: OLDER
CLIENT (PAIN)

• Older clients who have arthritis or

osteoporosis may experience neck pain
and a decreased range of motion.
HEAD AND FACE
 Inspection and Palpation
PROCEDURE NORMAL ABNORMAL

Inspect the head. Inspect Head size and shape
for size, shape, and vary, especially in accord
configuration. with ethnicity. Usually the
head is symmetric,
round, erect, and in
midline. No lesions are
visible.
The skull and facial
bones are larger and
thicker in acromegaly,
which occurs when there
is an increased
production of growth
hormone.

Acorn-shaped, enlarged
skull bones are seen in
Paget’s disease of the
bone.
Acorn
shaped
head
 SPECIAL CONSIDERATION: NEWBORN
At birth •Head circumference is greater (by 2 cm)
than that of the chest
•The cranial bones are soft and separated
by the coronal, lambdoid, and sagittal
sutures, which intersect at the anterior
and posterior fontanelle
•The newborn’s skull is typically
asymmetric (plagiocephaly) because of
molding that occurs as the newborn
passes through the birth canal.
2 months •Posterior fontanelle (1-2cm) closes.

Between 12-18 months •Anterior fontanelle (4-6 cm)closes.

 Inspection and Palpation
PROCEDURE NORMAL ABNORMAL

Inspect for involuntary Head should be held Tremors associated

movement. still and upright. with neurologic
disorders may cause a
horizontal jerking
movement. An
involuntary nodding
movement may be
seen in patients with
aortic insufficiency.
Head tilted to one side
may indicate unilateral
vision or hearing
deficiency or
shortening of the
sternomastoid muscle.
 Inspection and Palpation

PROCEDURE NORMAL ABNORMAL

Palpate the head. The head is normally Lesions or lumps on the

Palpate for hard and smooth head may indicate recent
consistency. without lesions. trauma or cancer.
 Inspection and Palpation
PROCEDURE NORMAL ABNORMAL

Inspect the The face is •Asymmetry in front of the earlobes occurs

face. Inspect symmetric with a with parotid gland enlargement from an
for symmetry, round, oval, abscess or tumor.
features, elongated, or square •Unusual or asymmetric orofacial
movement, appearance. No movements may be from an organic
expression, abnormal disease or neurologic problem, which
and skin movements noted. should be referred for medical follow-up.
condition. •Drooping of one side of the face may
result from a stroke or Bell’s palsy.
•A “masklike” face marks Parkinson’s
disease; a “sunken” face with depressed
eyes and hollow cheeks is typical of
cachexia;
•a pale, swollen face may result from
nephrotic syndrome.
 CLINICAL TIP!

• The nasolabial folds and palpebral fissures

are ideal places to check facial features for
symmetry.
Nasolabial folds
 SPECIAL CONSIDERATION: OLDER
CLIENTS
• In older clients, facial wrinkles are
prominent because subcutaneous fat
decreases with age. In addition, the lower
face may shrink and the mouth may be
drawn inward as a result of resorption of
mandibular bone, also an age-related
process.
 Inspection and Palpation

PROCEDURE NORMAL ABNORMAL

Palpate the The temporal artery is The temporal artery is hard,

temporal artery, elastic and not tender. thick, and tender with
which is located inflammation as seen with
between the top of temporal arteritis
the ear and the (inflammation of the temporal
eye arteries that may lead to
blindness).
SPECIAL CONSIDERATION: OLDER
CLIENTS

• The strength of the pulsation of the

temporal artery may be decreased in the
older client.
 Inspection and Palpation
PROCEDURE NORMAL ABNORMAL

Palpate the Normally there is no Limited range of

temporomandibular swelling, tenderness, or motion, swelling, ten-
joint. To assess the crepitation with movement. derness, or crepitation
temporomandibular Mouth opens and closes may indicate TMJ
joint (TMJ), place fully (3 to 6 cm between syndrome.
your index finger upper and lower teeth).
over the front of Lower jaw moves laterally 1
each ear as you ask to 2 cm in each direction.
the client to open
her mouth.
 CLINICAL TIP!
• When assessing TMJ syndrome, be sure
to explore the client’s history of
headaches, if any.
THE NECK
 Inspection

PROCEDURE NORMAL ABNORMAL

Inspect the neck. Neck is symmetric Swelling, enlarged masses,

Observe the client’s with head centered or nodules may indicate an
slightly extended and without bulging enlarged thyroid gland ,
neck for position, masses. inflammation of lymph nodes,
symmetry, and lumps or a tumor.
or masses. Shine a
light from the side of
the neck across to
highlight any swelling.
 Inspection

PROCEDURE NORMAL ABNORMAL

Inspect movement of The thyroid Asymmetric movement or

the neck structures. cartilage, cricoid generalized enlargement of
Ask the client to cartilage, and the thyroid gland is
swallow a small sip of thyroid gland move considered abnormal.
water. Observe the upward
movement of the symmetrically as
thyroid cartilage, the client swallows.
thyroid gland.
 Inspection

PROCEDURE NORMAL ABNORMAL

Inspect the cervical C7 (vertebrae Prominence or swellings

vertebrae. Ask the prominens) is other than the C7 vertebrae
client to flex the neck usually visible and may be abnormal.
(chin to chest, ear to palpable.
shoulder, twist left to
right and right to left,
and backward and
forward).
 SPECIAL CONSIDERATION: OLDER
CLIENTS

• In older clients, cervical curvature may

increase because of kyphosis of the spine.
Moreover, fat may accumulate around the
cervical vertebrae (especially in women). This
is sometimes called a “dowager’s hump.”
SPECIAL CONSIDERATION: NEWBORN

• The neck is usually short during infancy

(lengthening at about age 3 or 4 years).
Lymphoid tissue is well developed at birth
and reaches adult size by age 6 years.
 Inspection

PROCEDURE NORMAL ABNORMAL

Inspect range of Normally neck Muscle spasms,

motion. Ask the client movement should inflammation, or cervi- cal
to turn the head to the be smooth and arthritis may cause stiffness,
right and to the left controlled with 45- rigidity, and limited mobility of
(chin to shoulder), degree flexion, 55- the neck, which may affect
touch each ear to the degree extension, daily functioning.
shoulder, touch chin 40-degree lateral
to chest, and lift the abduction, and 70-
chin to the ceiling. degree rotation.
 SPECIAL CONSIDERATION: OLDER
CLIENTS

• Older clients usually have somewhat

decreased flexion, extension, lateral bending,
and rotation of the neck. This is usually due to
arthritis.
 PALPATION
PROCEDURE NORMAL ABNORMAL

Palpate the trachea. Trachea is midline. The trachea may be pulled to

Place your finger in one side in cases of a tumor,
the sternal notch. thyroid gland enlarge- ment,
Feel each side of the aortic aneurysm,
notch and palpate the pneumothorax, atelectasis,
tracheal rings. The or fibrosis.
first upper ring above
the smooth tracheal
rings is the cricoid
cartilage.
 PALPATION
PROCEDURE NORMAL ABNORMAL

Palpate the thyroid gland. Landmarks are Landmarks deviate from

Locate key landmarks with positioned midline or are obscured
your index finger and thumb: midline. because of masses or
Hyoid bone (arch-shaped abnormal growths.
bone that does not articulate
directly with any other bone;
located high in anterior neck).
Thyroid cartilage (under the
hyoid bone; the area that
widens at the top of the tra-
chea), also known as the
“Adam’s apple.”
Cricoid cartilage (smaller
upper tracheal ring under the
thyroid cartilage).
 PALPATION
PROCEDURE NORMAL ABNORMAL

To palpate the thyroid, use a Unless the client is In cases of diffuse

posterior approach. Stand behind extremely thin with enlargement; such as
the client and ask her or him to a long neck, the hyperthyroidism, Graves’
lower the chin to the chest and thyroid gland is disease, or an endemic
turn the neck slightly to the right. usually not palpable. goiter, the thyroid gland
This will relax the client’s neck However, the may be palpated. An
muscles. Then place your thumbs isthmus may be enlarged, tender gland
on the nape of the client’s neck palpated in midline. may result from
with your other fingers on either If the thyroid can be thyroiditis. Multiple
side of the trachea below the palpated, the lobes nodules of the thyroid
cricoid cartilage. Use your left are smooth, firm, may be seen in metabolic
fingers to push the trachea to the and nontender. The processes. However,
right. Then use your right fingers right lobe is often rapid enlargement of a
to feel deeply in front of the 25% larger than the single nodule suggests a
sternomastoid muscle left lobe. malignancy and must be
evaluated further.
 SPECIAL CONSIDERATION: OLDER
CLIENTS

• If palpable, the older client’s thyroid may

feel more nodular or irregular because of
fibrotic changes that occur with aging; the
thyroid may also be felt lower in the neck
because of age-related structural changes.
 PALPATION
PROCEDURE NORMAL ABNORMAL

Ask the client to swallow as Glandular thyroid Coarse tissue or

you palpate the right side of tissue may be felt irregular consistency
the gland. Reverse the rising underneath may indicate an
technique to palpate the left your fingers. inflammatory process.
lobe of the thyroid. Lobes should feel Nodules should be
smooth, rubbery, described in terms of
and free of location, size, and
nodules. consistency
 AUSCULTATION
PROCEDURE NORMAL ABNORMAL

Auscultate the thyroid only if No bruits are A soft, blowing,

you find an enlarged thyroid auscultated. swishing sound
gland during inspection or auscul- tated over the
palpation. Place the bell of thyroid lobes is often
the stethoscope over the heard in
lateral lobes of the thyroid hyperthyroidism
gland (Fig. 14-13). Ask the because of an
client to hold his breath (to increase in blood flow
obscure any tracheal breath through the thyroid
sounds while you auscultate). arteries.
SPOTLIGHT TECHNIQUE: PALPATING
THE LYMPH NODES
 General Guidelines for Palpation
1. Have the client remain seated upright.
2. Palpate the lymph nodes with your fingerpads in
a slow walking, gentle, circular motion.
3. Ask the client to bend the head slightly toward
the side being palpated to relax the muscles in
that area.
4. Compare lymph nodes that occur bilaterally. As
you palpate each group of nodes, assess their
size and shape, delimitation (whether they are
discrete or confluent), mobility, consistency, and
tenderness.
5. Choose a particular palpation sequence.
 CLINICAL TIP!
• Which sequence you choose is not
important. What is important is that you
establish a specific sequence that does
not vary from assessment to assessment.
This helps to guard against skipping a
group of nodes
Characteristics of the Lymph Nodes
• While palpating the lymph nodes, note the
following:
– Size and shape
– Delimitation
– Mobility
– Consistency
– Tenderness and location
Characteristics of the Lymph Nodes
Size and Shape •Normally lymph nodes, which are round and
smaller than 1 cm, are not palpable.
•When lymph node enlargement exceeds 1 cm, the
client is said to have lymphadenopathy, which may
be caused by acute or chronic infection, an
autoimmune disorder, or metastatic disease.
•If one or two lymphatic groups enlarge, the client
is said to have regional lymphadenopathy.
•Enlargement of three or more groups is
generalized lymphadenopathy.
•Generalized lymphadenopathy that persists for
more than 3 months may be a sign of human
immunodeficiency virus (HIV) infection.
 SPECIAL CONSIDERATION: OLDER
CLIENT
• In older clients especially, the lymph nodes
be- come fibrotic, fatty, and smaller
because of a loss of lymphoid elements
related to aging. (This may decrease the
older person’s resistance to infection.)
 Characteristics of the Lymph Nodes
Delimitation •Normally lymph node delimitation (the lymph node’s
position or boundary) is discrete.
• In chronic infection, however, the lymph nodes become
confluent (they merge).
•In acute infec- tion, they remain discrete.
Mobility •Typical lymph nodes are mobile both from side to side
and up and down.
• In metastatic disease, the lymph nodes enlarge and
become fixed in place.
Consistency •Somewhat more fibrotic and fatty in older clients, the
normal lymph node is soft, whereas the abnormal node is
hard and firm. Hard, firm, unilateral nodes are seen with
metastatic cancers.
Tenderness and •Tender, enlarged nodes suggest acute infections;
Location normally lymph nodes are not sore or tender. Of course,
you need to doc- ument the location of the lymph node
being assessed.
Lymph Nodes of the Head and
Neck
 PALPATION

PROCEDURE NORMAL ABNORMAL

Palpate the preauricular There is no Enlarged nodes are

nodes (in front of the ear), swelling or abnormal.
postauricular nodes (behind enlargement and
the ears), occipital nodes (at no tenderness.
the poste- rior base of the
skull).
 PALPATION

PROCEDURE NORMAL ABNORMAL

Palpate the tonsillar nodes at No swelling, no Swelling, tenderness,

the angle of the mandible on tenderness, no hardness, immo- bility
the anterior edge of the hardness is are abnormal.
sternomastoid muscle present.
 PALPATION

PROCEDURE NORMAL ABNORMAL

Palpate the submandibular No enlargement or Enlargement and

nodes located on the medial tenderness is tenderness are
border of the mandible present. abnormal.

CLINICAL TIP! Do not confuse the submandibular nodes with the

lobulated submandibular gland.
 PALPATION

PROCEDURE NORMAL ABNORMAL

Palpate the submental nodes, No enlargement or Enlargement and

which are a few centimeters tenderness is tenderness are
behind the tip of the mandible present abnormal.

CLINICAL TIP! It is easier to palpate these nodes using one hand.

 PALPATION
PROCEDURE NORMAL ABNORMAL

Palpate the superficial cervical No enlargement or Enlargement and

nodes in the area superficial to tenderness is tenderness are
the sternomastoid muscle. present. abnormal.

Palpate the posterior cervical No enlargement or Enlargement and

nodes in the area posterior to the tenderness is tenderness are
sternomastoid and anterior to the present. abnormal.
trapezius in the posterior triangle.
 PALPATION
PROCEDURE NORMAL ABNORMAL

Palpate the deep cervical chain No enlargement or Enlargement and

nodes deeply within and around tenderness is tenderness are
the sternomastoid muscle. present. abnormal.

Palpate the supraclavicular No enlargement or An enlarged, hard,

nodes by hooking your fingers tenderness is nontender node, par-
over the clavicles and feeling present. ticularly on the left side,
deeply between the clavi- cles may indicate a
and the sternomastoid muscles metastasis from a
malignancy in the
abdomen or thorax.
HEAD AND NECK
ABNORMALITIES