Week 6 Ha Student

Head, Mouth, Nose, Throat, Neck and Regional Lymph NodesKristin Clephane, MSN, RN, CPN

The HeadSkull- rigid, bony box (or vault) includes bones of cranium and face.Cranial Bones:Frontal, Parietal, Occipital, and Temporal Sutures- Immovable Joints (not joined at birth to allow mobility during birth)Coronal, Saggittal, Lambdoid SuturesFacial Bone: Only the mandible moves (TMJ)

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The Head

The HeadGlands of the HeadSalivary- Three pairs of glands, located bilaterally. (only two palpable).

Parotid- Largest salivary gland, not normally palpable.Submandibular- beneath mandible.Sublingual- floor of the mouth.

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The NeckConduit for passage of:Vessels, muscles, nerves, lymphatics, respiratory organs (air), digestive organs (food and fluid).Also contains: Thyroid GlandEndocrine gland that controls metabolism.Two major muscle groups: Sternomastoid and Trapezius.Anterior triangle- in front between sternomastoid and midline, with base along mandible.Posterior triangle- between sternomastoid and trapezius and base along clavicle.

The NeckCartilage/Bones of the neckCricoid cartilageIn front of trachea, protects breathing.Thyroid cartilageAbove cricoid cartilage, protects thyroid.Adams apple.Hyoid BoneHigh, at the level of the floor of the mouth.(Remember the vertebrae)

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The Neck

LymphaticsLymph System drains the immunologic waste products.Lymph Node in the head and neck:Preauricular In front of ear.Posterior auricular (mastoid) Behind the ear.Occipital - Base of skullSubmental - Under the chinSubmandibular Under the jaw on the sides.Jugulodigastric Under the bend of the mandible.Superficial cervical On top of the sternomastoid muscle.Deep cervical Under the sternomastoid muscle.Posterior cervical In posterior triangle near trapezius.Supraclavicular Above and behind the clavicle at the sternomastoid muscle.

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Lymph Nodes

LymphaticsDrainage:Since the lymph system drains immunologic waste, look above and below the node for problems draining.Basically another vessel (like blood vessels).Located throughout body, but can only be examined (without diagnostic testing) in the head, neck, arm, axillae, and inguinal areas.

Developmental: Infants and ChildrenFontanels- spaces where the sutures in the skull intersect.Covered by soft spots, will ossify (close).Allow for growth during the first year.Head is 90% its full size by age six, (then the rest of the body catches up).Lymphoid tissue well developed at birth.

Developmental:Preganancy

Thyroid gland enlarges during pregnancy.Aging Adult

Facial bones and orbits appear more prominent.Sagging skin.

History/Subjective AssessmentAsk patient if the have a history of:HeadachesOnset, Location, Character, Duration, Precipitating Factors, Alleviating Factors, Pattern, Treatment.Head InjuryOnset, Location, Duration, Associated symptoms, Pattern, Treatment.DizzinessLightheadedness vs. Falling vs. Spinning, Onset, Associated FactorsNeck PainOnset, Location, Associated Symptoms, Precipitating Factors, Treatment.Lumps or swellingRecent infection/tenderness, History of: radiation, smoking, chew tobacco, thyroid problems.Head or neck surgeryWhat surgery, when, where, and outcome.

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History/Subjective AssessmentFor Aging Adult Add:If dizziness occurs, how does it affect ADLs? Can you walk/drive safely?If neck pain, How does it affect ADLs? Can you drive/work/do housework/sleep/look down stairs?For Children Add:Did mother use ETOH or street drugs? How much and how often?Delivery vaginal or C-section? Any problems?Was babys growth normal?

Assessment/Objective DataInspect and Palpate the Skull

Normocephalic normal size and shape.Temporal Area- Palpate the temporal artery.TMJ- palpate this joint.

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Assessment/Objective DataInspect the FaceFacial Structures- appropriateness to behavior and mood.Note symmetryNote involuntary movements.Note abnormal features or swelling.

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Assessment/Objective DataInspect and Palpate the Neck

Symmetry head midline, muscles symmetricalROM ask pt to:Touch chin to chest, turn head left and right, touch ear to each shoulder, extend head backwards (look up).Test strength (Cranial nerve XI) by adding resistance to persons attempt to shrug shoulders.Look for enlargement of salivary glands, thyroid gland and lymph nodes.

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Assessment/Objective DataInspect and Palpate the NeckSymmetry, ROMLYMPH NODESUse gentle circular motion of fingerpads to palpate lymph nodes.Begin with preauricular lymph nodes and follow side to side and downward assessment. P 261 in text.

Assessment/Objective DataLymph NodesIf any nodes are palpable, note location, size, shape, delimitation, mobility, consistency, and tenderness.(Normal- Movable, discrete, soft and nontender).If abnormal, assess drainage vessels for problems: such as pulsating, absent pulse, weak pulse.

Assessment/ Objective DataTracheaShould be midline. Slide finger from sternal notch to either side, should be equal.

Assessment/Objective DataThyroid gland

Posterior approach- move behind the pt., Push with left hand, palpate with right. (then reverse)Anterior approach- Push with right thumb, palpate with left thumb (then reverse). Ask pt to swallow. Thyroid assessmentAuscultate Listen for bruit (this is abnormal).Link: Bruits in thyroidSlide 13-*

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Questions?

Nose, Mouth and Throat

The NoseFirst segment of respiratory system.Nasal Cavity- Extends back over the roof of the mouth, covered with virissae(hair) and cilliated mucous membranes.Septum- Divides the nose, most common site of nose bleeds, highly vascular.Turbinates- Three bony projections that increase surface area for humidification, filtration, and warmth.Meatus- cleft in the turbinates, allows drainage.Nares- Nostrils

Nasal Cavity

The SinusesParanasal Sinuses- air-filled pockets in the head.

Lined with mucous membranes.Drain mucous (EASILY BLOCKED).Resonate sound (upon percussion)Include the frontal, maxillary, ethmoid and sphenoid sinuses.

The SinusesOnly two pairs of sinuses are easily assessable: Frontal and Maxillary.Sinuses mature and develop as we age, only maxillary and ethmoid sinuses are present at birth.

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MouthOral Cavity- contains teeth, tongue, salivary glands, bordered by lips, palate, cheeks and tongue.Hard Palate- In front part of mouth (anterior) made of bone.Soft Palate- Farther back in mouth, made of muscle.Uvula- The dangling thing in the back of your mouth.

Mouth

MouthTongue- Large muscle, use for taste, speech, aids in mastication.Frenulum- Connects the tongue to floor of the mouth.Parotid gland- Bilateral cheeks, opens in buccal mucosa (sides of mouth).Submandibular gland- Walnut sized, bilateral under jaw, opens under tongue on floor of mouth.Sublingual gland- Under the tongue on floor of the mouth. Many small openings.Permanent Teeth- 32 teethGums (gingivae)- hold teeth in place, covered with mucous membranes.

ThroATPharynx (throat)- area behind mouth and nose.Oropharynx- separated from mouth by a fold of tissue.Tonsils- located in oropharynx, made of lymphoid tissue.Nasopharynx- continuous with oropharynx, located behind nasal cavity. Contains pharyngeal tonsils (adenoids) and eustacian tube opening.

Aging AdultDecreased sense of smell.Nose hair longer and coarse. (should not clip, may cause infection).Decreased sense of taste (loss of taste buds).Higher risk of oral infections due to thinning of tissue.Increased tooth loss.Malocclusion- related to tooth loss (difficulty chewing, pain with chewing). May not be able to fully open the mouth. Encourage soft foods.

Cross-Cultural Native Americans and Asians- bifid uvula (split in two) more common.Native Americans and Asians- cleft lip and cleft palate more common.Native Americans, Asians, and Inuits- Torus palatinus (bony ridge on hard palate) more common.Blacks- Leukoedema (benign) grey-white lesion on buccal mucosa (68-90%) very common.Whites- most likely to have tooth decay.However, African-Americans, Hispanics, Native Americans, and Alska Natives more likely to loose teeth or have untreated cavities.African-American males- highest rate of oral and pharyngeal cancers, with much poorer prognosis.

Health History/Subjective DataNose:

DischargeFrequent coldsSinus painTraumaEpistaxis AllergiesAltered smell

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Health History/Subjective DataMouthSores/lesionsSore throatBleeding gumsToothacheHoarsenessDysphagiaAltered tasteSmoking/AlcoholSelf-Care behaviors (dentist, dentures)

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Health History/Subjective DataAdditional history for infants and childrenMouth infectionSore throatTooth eruptionSelf-care

Additional history for the aging adultMouth drynessTooth lossCare of teeth, denturesTaste, smell

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Objective DataPhysical ExamPreparationPositioning- sitting upright, head at eye level.EquipmentOtoscope with short, wide-tipped nasal speculum attachmentPenlightTwo tongue bladesCotton gauze pad (4 4 inches)GlovesLong-stem light attachment for otoscope (occasionally)Slide 16-*

Objective DataPhysical Exam (cont.)NoseInspect and palpateExternal noseSymmetric, midline, proportional.Any deformities?Nasal cavityPatent- occlude one nare at a time.Nasal septum- Deviated?Turbinates- Swelling? Color?

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Objective DataPhysical Exam (cont.)Sinus AreasPalpateFrontal and maxillary sinuses (Press gently with thumbs)

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Objective DataPhysical Exam MouthInspectLips- color, moisture, cracking, lesions.Teeth and gums- White, straight, and evenly spaced, clean and free of debris or decay.Tongue- color, surface characteristics, moisture. Look for patches or lesions.Palpate U-shape under tongue (most likely place for cancer.)Buccal mucosa- Color, nodules,lesions, moisture.Slide 16-* Pat Thomas, 2006.

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Objective Data/Physical ExamHard Palate- Hard, white with rugae. Soft Palate- Soft, pink, smooth, and upwardly mobile.Uvula- Should rise up when person says Ahh. (Cranial Nerve X)

Objective DataPhysical Exam ThroatInspectionTonsils grading (pictured)1+=Visible, 2+ halfway between tonsillar pillars and uvula, 3+ touching the uvula, 4+ touching each other.Posterior pharyngeal wall- will trigger the GAG REFLEX!! (cranial nerves IX and X)Stick out your tongue should be midline. (cranial nerve XII)Slide 16-*

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Objective Data: MouthGloved hand > hold tongue with gauze > move tongue out and to each side > with pen light, look for any lesions/patches

Gloved hands > one under jaw to stabilize > other hand, one finger palpates under tongue around jaw line for any lumps, pain

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Questions?

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