Examination of the Head and Neck Part 1
Nose and Sinuses, Lips, Mouth, Teeth, Tongue, and Pharynx
Examination of the Head and Neck Part 2
At least nine clinical specialties have a major focus on the head and neck: neurology, neurosurgery, ophthalmology, otolaryngology, plastic surgery, radiology, radiation oncology, oral surgery, and dentistry. Each specialty has developed detailed examinations to meet their needs, often with the use of specialized instruments. We describe examinations that can be made with the resources available to the general clinician. Presentation of the entire range of potential diagnoses is beyond the scope of this book. Traumatic disorders are not considered.
Examination of the head, neck, and cranial nerves is an essential part of the neurologic examination. Interpretation of physical examination findings is done with an eye to both the local findings and the pattern of neurologic abnormalities. This chapter discusses the physical examination, symptoms, and signs of the head and neck; for signs of primarily neurologic significance, we refer the reader to the appropriate section of the neurologic examination in Chapter 14 to discuss the finding and its interpretation. The major syndromes specific to the head and neck organs, exclusive of the central nervous system, are discussed in this chapter, while the neurologic syndromes are discussed in Chapter 14. By necessity, these distinctions are somewhat arbitrary.
In the general head and neck examination, the examiner should: (1) identify signs of generalized disease, (2) recognize local lesions within the purview of the generalist, and (3) recognize local lesions requiring specialist care.
The head and neck contain a complicated grouping of major structures all within close proximity to one another. The examiner must always be aware of the anatomy and functional physiology of the superficial and deep structures being examined.
The skull, facial bones, and scalp provide protection and insulation to the deeper structures. The scalp and face are rich in blood vessels that vasodilate in response to cold to maintain normal body temperatures within these vital structures. The head contains the organs of special sense: the eyes, ears, olfactory nerve, and taste buds of the tongue. Impairment of the special senses suggests either problems with the sensory organs, their cranial nerves, or the brain. The tongue, pharynx, and larynx are the organs of speech. Changes in articulation suggest anatomic or functional problems with these structures. The nose, mouth, pharynx, larynx, and trachea form the upper airways; any compromise of these structures may impair effective respiration and effect changes in the tone or volume of voice. The mouth, teeth, mandible and maxilla, tongue, salivary glands, pharynx, and upper esophagus are the upper alimentary tract necessary for mastication and swallowing of food. Impairment of these structures may result in nutritional deficiency. The head and neck structures are highly vascular. The superficial structures have rich anastomoses from branches of the external carotid, so ischemic injury is unusual. The internal carotid and vertebral arteries supply blood to the brain. The head and neck have a rich lymphatic network draining to several discrete regional lymph node beds. In addition, the tonsils and adenoids are lymphatic organs surrounding the upper aerodigestive tract. The neck contains the thyroid and parathyroid glands, major structures of the endocrine system.
The scalp has five layers: the skin, subcutaneous connective tissue, epicranius, a subfascial cleft with loose connective tissue, and the pericranium (Fig. 7–1). Functionally, the outer three are a single thick, tough, and vascular layer. The epicranius; covering the vertex of the skull, is formed by the frontalis muscle attached to the occiput by a large central aponeurosis; the galea aponeurotica. The skin and subcutaneous tissue are tightly bound to the galea by many fibrous bands that sharply limit the spread of blood and pus. The pericranium is the periosteal layer of the bones of the skull; it dips into the suture lines, limiting subperiosteal blood or pus to the surface of a single bone. Between the pericranium and the galea is a fascial cleft containing loose connective tissue. Because of this layer, the lacerated scalp can be lifted from the skull with minimal effort and blood or pus can spread widely beneath it. A useful pneumonic for remembering this structure is SCALP: Skin, Connective tissue, Aponeurosis, Loose connective tissue, Periosteum.
Layers of the Scalp.For practical purposes, the cutis, subcutis, and galea aponeurotica constitute a single, thick, tough layer with fibrous bands compartmentalizing the more superficial tissue and binding it to the galea. Between the galea and the pericranium is a potential space with a little areolar tissue. Fluid and infection spread slowly through the compartments above the galea, but spread easily through the space beneath the galea and its attached muscles (the epicranium). The pericranium is the periosteal layer that covers the bones of the skull and dips inward at the suture lines. Subperiosteal fluid is limited to the area over a single bone.
The scalp has three areas of lymphatic drainage. The forehead and the anterior portion of the parietal bone drain to the preauricular lymph node. The mid-parietal region drains first to the postauricular node and then into the nodes of the posterior cervical triangle. The occipital area drains first into the nodes at the origin of the trapezius, and then into the posterior cervical triangle...