Learning Objectives

• Perform a head and neck assessment, including the skull, face, nose, oral cavity, and neck
• Modify assessment techniques to reflect variations across the life span
• Recognize and report significant deviations from norms
• Document actions and observations

Inspection of a patient’s head, neck, and oral cavity is part of the routine daily assessment performed by a registered nurse (RN) during inpatient care.^[1] There are also several head and neck conditions that the RN may be the first to notice after a patient is admitted that require notification of the health care provider. Let’s get started by reviewing the basic anatomy and physiology of the head and neck and common medical conditions.

References

1.

Giddens, J. F. (2007). A survey of physical examination techniques performed by RNs: Lessons for nursing education. Journal of Nursing Education, 46(2), 83-87.  10.3928/01484834-20070201-09 ↵. [PubMed: 17315568] [CrossRef]

Anatomy

Skull

The anterior skull consists of facial bones that provide the bony support for the eyes and structures of the face. This anterior view of the skull is dominated by the openings of the orbits, the nasal cavity, and the upper and lower jaws. See Figure 7.1^[1] for an illustration of the skull. The orbit is the bony socket that houses the eyeball and the muscles that move the eyeball. Inside the nasal area of the skull, the nasal cavity is divided into halves by the nasal septum that consists of both bone and cartilage components. The mandible forms the lower jaw and is the only movable bone in the skull. The maxilla forms the upper jaw and supports the upper teeth.^[2]

Figure 7.1

Skull

The cranium, or “brain case”, surrounds and protects the brain that occupies the cranial cavity. See Figure 7.2^[3] for an image of the brain within the cranial cavity. The brain case consists of eight bones, including the paired parietal and temporal bones plus the unpaired frontal, occipital, sphenoid, and ethmoid bones.^[4]

Figure 7.2

Cranial Cavity

A suture is an interlocking joint between adjacent bones of the skull and is filled with dense, fibrous connective tissue that unites the bones. In a newborn infant, the pressure from vaginal delivery compresses the head and causes the bony plates to overlap at the sutures, creating a small ridge. Over the next few days, the head expands, the overlapping disappears, and the edges of the bony plates meet edge to edge. This is the normal position for the remainder of the life span and the sutures become immobile.

See Figure 7.3^[5] for an illustration of two of the sutures, the coronal and squamous sutures, on the lateral view of the head. The coronal suture is seen on the top of the skull. It runs from side to side across the skull and joins the frontal bone to the right and left parietal bones. The squamous suture is located on the lateral side of the skull. It unites the squamous portion of the temporal bone with the parietal bone. At the intersection of the coronal and squamous sutures is the pterion, a small, capital H-shaped suture line region that unites the frontal bone, parietal bone, temporal bone, and greater wing of the sphenoid bone. The pterion is an important clinical landmark because located immediately under it, inside the skull, is a major branch of an artery that supplies the brain. A strong blow to this region can fracture the bones around the pterion. If the underlying artery is damaged, bleeding can cause the formation of a collection of blood, called a hematoma, between the brain and interior of the skull, which can be life-threatening.^[6]

Figure 7.3

Coronal Sutures in Lateral View of Skull

Paranasal Sinuses

The paranasal sinuses are hollow, air-filled spaces located within the skull. See Figure 7.4^[7] for an illustration of the sinuses. The sinuses connect with the nasal cavity and are lined with nasal mucosa. They reduce bone mass, lightening the skull, and also add resonance to the voice. When a person has a cold or sinus congestion, the mucosa swells and produces excess mucus that often obstructs the narrow passageways between the sinuses and the nasal cavity. The resulting pressure produces pain and discomfort.^[8]

Figure 7.4

Sinuses

Each of the paranasal sinuses is named for the skull bone that it occupies. The frontal sinus is located just above the eyebrows within the frontal bone. The largest sinus, the maxillary sinus, is paired and located within the right and left maxillary bones just below the orbits. The maxillary sinuses are most commonly involved during sinus infections. The sphenoid sinus is a single, midline sinus located within the body of the sphenoid bone. The lateral aspects of the ethmoid bone contain multiple small spaces separated by very thin, bony walls. Each of these spaces is called an ethmoid air cell.

Anatomy of Nose, Pharynx, and Mouth

See Figure 7.5^[9] to review the anatomy of the head and neck. The major entrance and exit for the respiratory system is through the nose. The bridge of the nose consists of bone, but the protruding portion of the nose is composed of cartilage. The nares are the nostril openings that open into the nasal cavity and are separated into left and right sections by the nasal septum. The floor of the nasal cavity is composed of the palate. The hard palate is located at the anterior region of the nasal cavity and is composed of bone. The soft palate is located at the posterior portion of the nasal cavity and consists of muscle tissue. The uvula is a small, teardrop-shaped structure located at the apex of the soft palate. Both the uvula and soft palate move like a pendulum during swallowing, swinging upward to close off the nasopharynx and prevent ingested materials from entering the nasal cavity.^[10]

Figure 7.5

Anatomy of the Head and Neck

As air is inhaled through the nose, the paranasal sinuses warm and humidify the incoming air as it moves into the pharynx. The pharynx is a tube-lined mucous membrane that begins at the nasal cavity and is divided into three major regions: the nasopharynx, the oropharynx, and the laryngopharynx.^[11]

The nasopharynx serves only as an airway. At the top of the nasopharynx is the pharyngeal tonsil, commonly referred to as the adenoids. Adenoids are lymphoid tissue that trap and destroy invading pathogens that enter during inhalation. They are large in children but tend to regress with age and may even disappear.^[12]

The oropharynx is a passageway for both air and food. The oropharynx is bordered superiorly by the nasopharynx and anteriorly by the oral cavity. The oropharynx contains two sets of tonsils, the palatine and lingual tonsils. The palatine tonsil is located laterally in the oropharynx, and the lingual tonsil is located at the base of the tongue. Similar to the pharyngeal tonsil, the palatine and lingual tonsils are composed of lymphoid tissue and trap and destroy pathogens entering the body through the oral or nasal cavities. See Figure 7.6^[13] for an image of the oral cavity and oropharynx with enlarged palatine tonsils.

Figure 7.6

Oral Cavity and Oropharynx

The laryngopharynx is inferior to the oropharynx and posterior to the larynx. It continues the route for ingested material and air until its inferior end where the digestive and respiratory systems diverge. Anteriorly, the laryngopharynx opens into the larynx and posteriorly, it enters the esophagus that leads to the stomach. The larynx connects the pharynx to the trachea and helps regulate the volume of air that enters and leaves the lungs. It also contains the vocal cords that vibrate as air passes over them to produce the sound of a person’s voice. The trachea extends from the larynx to the lungs. The epiglottis is a flexible piece of cartilage that covers the opening of the trachea during swallowing to prevent ingested material from entering the trachea.^[14]

Muscles and Nerves of the Head and Neck

FACIAL MUSCLES

Several nerves innervate the facial muscles to create facial expressions. See Figure 7.7^[15] for an illustration of nerves innervating facial muscles. These nerves and muscles are tested during a cranial nerve exam. See more information about performing a cranial nerve exam in the “Neurological Assessment” chapter.

Figure 7.7

Nerve Branches Innervating Facial Muscles

When a patient is experiencing a cerebrovascular accident (i.e., stroke), it is common for facial drooping to occur. Facial drooping is an asymmetrical facial expression that occurs due to damage of the nerve innervating a specific part of the face. See Figure 7.8^[16] for an image of facial drooping occurring on the patient’s right side of their face.

Figure 7.8

Facial Drooping

NECK MUSCLES

The muscles of the anterior neck assist in swallowing and speech by controlling the positions of the larynx and the hyoid bone, a horseshoe-shaped bone that functions as a solid foundation on which the tongue can move. The head, attached to the top of the vertebral column, is balanced, moved, and rotated by the neck muscles. When these muscles act unilaterally, the head rotates. When they contract bilaterally, the head flexes or extends. The major muscle that laterally flexes and rotates the head is the sternocleidomastoid. The trapezius muscle elevates the shoulders (shrugging), pulls the shoulder blades together, and tilts the head backwards. See Figure 7.9^[17] for an illustration of the sternocleidomastoid and trapezius muscles.^[18]Both of these muscles are tested during a cranial nerve assessment. See more information about cranial nerve assessment in the “Neurological Assessment” chapter.

Figure 7.9

Neck Muscles

JAW MUSCLES

The masseter muscle is the main muscle used for chewing because it elevates the mandible (lower jaw) to close the mouth. It is assisted by the temporalis muscle that retracts the mandible. The temporalis muscle can be felt moving by placing fingers on the patient’s temple as they chew. See Figure 7.10^[19] for an illustration of the masseter and temporalis muscles.^[20]

Figure 7.10

Masseter and Temporalis Muscles

TONGUE MUSCLES

Muscles of the tongue are necessary for chewing, swallowing, and speech. Because it is so moveable, the tongue facilitates complex speech patterns and sounds.^[21]

Airway and Unconsciousness

When a patient becomes unconscious and is lying supine, the tongue often moves backwards and blocks the airway. This is why it is important to open the airway when performing CPR by using a chin-thrust maneuver. See Figure 7.11^[22] for an image of the tongue blocking the airway. In a similar manner, when a patient is administered general anesthesia during surgery, the tongue relaxes and can block the airway. For this reason, endotracheal intubation is performed during surgery with general anesthesia by placing a tube into the trachea to maintain an open airway to the lungs. After surgery, patients often report a sore or scratchy throat for a few days due to the endotracheal intubation.^[23]

Figure 7.11

Airway Blocked by Tongue

SWALLOWING

Swallowing is a complex process that uses 50 pairs of muscles and many nerves to receive food in the mouth, prepare it, and move it from the mouth to the stomach. Swallowing occurs in three stages. During the first stage, called the oral phase, the tongue collects the food or liquid and makes it ready for swallowing. The tongue and jaw move solid food around in the mouth so it can be chewed and made the right size and texture to swallow by mixing food with saliva. The second stage begins when the tongue pushes the food or liquid to the back of the mouth. This triggers a swallowing response that passes the food through the pharynx. During this phase, called the pharyngeal phase, the epiglottis closes off the larynx and breathing stops to prevent food or liquid from entering the airway and lungs. The third stage begins when food or liquid enters the esophagus and it is carried to the stomach. The passage through the esophagus, called the esophageal phase, usually occurs in about three seconds.^[24]

View the following video from Medline Plus on the Swallowing Process:

Swallowing ^[25]

Dysphagia is the medical term for swallowing difficulties that occur when there is a problem with the nerves or structures involved in the swallowing process.^[26] Nurses are often the first to notice signs of dysphagia in their patients that can occur due to a multitude of medical conditions such as a stroke, head injury, or dementia. For more information about the symptoms, screening, and treatment for dysphagia, go to the “Common Conditions of the Head and Neck” section.

Lymphatic System

The lymphatic system is the system of vessels, cells, and organs that carries excess interstitial fluid to the bloodstream and filters pathogens from the blood through lymph nodes found near the neck, armpits, chest, abdomen, and groin. See Figure 7.12^[27] and Figure 7.13^[28] for an illustration of the lymph nodes found in the head and neck regions. When a person is fighting off an infection, the lymph nodes in that region become enlarged, indicating an active immune response to infection.^[29]

Figure 7.12

Lymphatic System

Figure 7.13

Lymph Nodes in Head and Neck

References

1.

“704 Skull -01.jpg” by OpenStax College is licensed under CC BY 3.0. Access for free at https://openstax​.org​/books/anatomy-and-physiology​/pages/7-2-the-skull ↵.

2.

This work is a derivative of Anatomy & Physiology by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax​.org​/books/anatomy-and-physiology​/pages/1-introduction ↵.

3.

This work is derivative of “727_Cranial_Fossae​.jpg” by OpenStax and is licensed under CC BY 3.0. Access for free at https://openstax​.org​/books/anatomy-and-physiology​/pages/7-2-the-skull ↵.

4.

This work is a derivative of Anatomy & Physiology by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax​.org​/books/anatomy-and-physiology​/pages/1-introduction ↵.

5.

“705 Lateral View of Skull-01.jpg” by OpenStax is licensed under CC BY 3.0. Access for free at https://openstax​.org​/books/anatomy-and-physiology​/pages/7-2-the-skull ↵.

6.

This work is a derivative of Anatomy & Physiology by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax​.org​/books/anatomy-and-physiology​/pages/1-introduction ↵.

7.

“Paranasal Sinuses ant.jpg” by OpenStax is licensed under CC BY-SA 3.0. Access for free at https://openstax​.org​/books/anatomy-and-physiology​/pages/7-2-the-skull ↵.

8.

This work is a derivative of Anatomy & Physiology by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax​.org​/books/anatomy-and-physiology​/pages/1-introduction ↵.

9.

"2303 Anatomy of Nose-Pharynx-Mouth-Larynx.jpg” by OpenStax is licensed CC BY 3.0 ↵.

10.

This work is a derivative of Anatomy & Physiology by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax​.org​/books/anatomy-and-physiology​/pages/1-introduction ↵.

11.

This work is a derivative of Anatomy & Physiology by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax​.org​/books/anatomy-and-physiology​/pages/1-introduction ↵.

12.

This work is a derivative of Anatomy & Physiology by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax​.org​/books/anatomy-and-physiology​/pages/1-introduction ↵.

13.

This work is a derivative of “2209 Location and Histology of Tonsils.jpg” by OpenStax and is licensed under CC BY 3.0 Access for free at https://openstax​.org​/books/anatomy-and-physiology​/pages/21-1-anatomy-of-the-lymphatic-and-immune-systems ↵.

14.

This work is a derivative of Anatomy & Physiology by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax​.org​/books/anatomy-and-physiology​/pages/1-introduction ↵.

15.

“Head facial nerve branches.jpg” by Patrick J. Lynch, medical illustrator is licensed under CC BY 2.5 ↵.

16.

“Stroke-facial-droop​.jpg” by Another-anon-artist-234 is licensed under CC0 1.0 ↵.

17.

“1111 Posterior and Side Views of the Next.jpg” by OpenStax is licensed under CC BY 4.0. Access for free at https://openstax​.org​/books/anatomy-and-physiology​/pages/11-3-axial-muscles-of-the-head-neck-and-back. ↵.

18.

This work is a derivative of Anatomy & Physiology by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax​.org​/books/anatomy-and-physiology​/pages/1-introduction ↵.

19.

“1108 Muscle that Move the Lower Jaw.jpg” by OpenStax is licensed under CC BY 4.0. Access for free at https://openstax​.org​/books/anatomy-and-physiology​/pages/11-3-axial-muscles-of-the-head-neck-and-back ↵.

20.

This work is a derivative of Anatomy & Physiology by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax​.org​/books/anatomy-and-physiology​/pages/1-introduction ↵.

21.

This work is a derivative of Anatomy & Physiology by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax​.org​/books/anatomy-and-physiology​/pages/1-introduction ↵.

22.

“Airway closed in an unconscious patient because the head inflexed forward.jpg” by Dr. Lorimer is licensed under CC BY-SA 4.0 ↵.

23.

This work is a derivative of Anatomy & Physiology by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax​.org​/books/anatomy-and-physiology​/pages/1-introduction ↵.

24.

National Institute on Deafness and Other Communication Disorders. (2017, March 6). Dysphagia. https://www​.nidcd.nih​.gov/health/dysphagia ↵.

25.

A.D.A.M. Medical Encyclopedia [Internet]. Atlanta (GA): A.D.A.M. Inc.; c1997-2021. Swallowing; [Video]. [updated 2019, July 11]. https://medlineplus​.gov​/ency/anatomyvideos/000126.htm ↵.

26.

National Institute on Deafness and Other Communication Disorders. (2017, March 6). Dysphagia. https://www​.nidcd.nih​.gov/health/dysphagia ↵.

27.

“2201 Anatomy of the Lymphatic System.jpg” by OpenStax College is licensed under CC BY 3.0. Access for free at https://openstax​.org​/books/anatomy-and-physiology​/pages/21-1-anatomy-of-the-lymphatic-and-immune-systems ↵.

28.

“Cervical lymph nodes and level.png” by Mikael Häggström, M​.D. is licensed under CC0 1.0 ↵.

29.

This work is a derivative of Anatomy & Physiology by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax​.org​/books/anatomy-and-physiology​/pages/1-introduction ↵.

Headache

A headache is a common type of pain that patients experience in everyday life and a major reason for missed time at work or school. Headaches range greatly in severity of pain and frequency of occurrence. For example, some patients experience mild headaches once or twice a year, whereas others experience disabling migraine headaches more than 15 days a month. Severe headaches such as migraines may be accompanied by symptoms of nausea or increased sensitivity to noise or light. Primary headaches occur independently and are not caused by another medical condition. Migraine, cluster, and tension-type headaches are types of primary headaches. Secondary headaches are symptoms of another health disorder that causes pain-sensitive nerve endings to be pressed on or pulled out of place. They may result from underlying conditions including fever, infection, medication overuse, stress or emotional conflict, high blood pressure, psychiatric disorders, head injury or trauma, stroke, tumors, and nerve disorders such as trigeminal neuralgia, a chronic pain condition that typically affects the trigeminal nerve on one side of the cheek.^[1]

Not all headaches require medical attention, but some types of headaches can signify a serious disorder and require prompt medical care. Symptoms of headaches that require immediate medical attention include a sudden, severe headache unlike any the patient has ever had; a sudden headache associated with a stiff neck; a headache associated with convulsions, confusion, or loss of consciousness; a headache following a blow to the head; or a persistent headache in a person who was previously headache free.^[2]

Concussion

A concussion is a type of traumatic brain injury caused by a blow to the head or by a hit to the body that causes the head and brain to move rapidly back and forth. This sudden movement causes the brain to bounce around in the skull, creating chemical changes in the brain and sometimes damaging brain cells.^[3] See Figure 7.14^[4] for an illustration of a concussion.

Figure 7.14

Concussion

A person who has experienced a concussion may report the following symptoms:

• Headache or “pressure” in head
• Nausea or vomiting
• Balance problems or dizziness or double or blurry vision
• Light or noise sensitivity
• Feeling sluggish, hazy, foggy, or groggy
• Confusion, concentration, or memory problems
• Just not “feeling right” or “feeling down”^[6]

The following signs may be observed in someone who has experienced a concussion:

• Can’t recall events prior to or after a hit or fall
• Appears dazed or stunned
• Forgets an instruction, is confused about an assignment or position, or is unsure of the game, score, or opponent
• Moves clumsily
• Answers questions slowly
• Loses consciousness (even briefly)
• Shows mood, behavior, or personality changes^[7]

Anyone suspected of experiencing a concussion should immediately be seen by a health care provider or go to the emergency department for further testing.

Head Injury

Head and traumatic brain injuries are major causes of immediate death and disability. Falls are the most common cause of head injuries in young children (ages 0–4 years), adolescents (15–19 years), and the elderly (over 65 years). Strong blows to the brain case of the skull can produce fractures resulting in bleeding inside the skull. A blow to the lateral side of the head may fracture the bones of the pterion. If the underlying artery is damaged, bleeding can cause the formation of a hematoma (collection of blood) between the brain and interior of the skull. As blood accumulates, it will put pressure on the brain. Symptoms associated with a hematoma may not be apparent immediately following the injury, but if untreated, blood accumulation will continue to exert increasing pressure on the brain and can result in death within a few hours.^[8]

See Figure 7.15^[9] for an image of an epidural hematoma indicated by a red arrow associated with a skull fracture.

Figure 7.15

Skull Fracture and Hematoma

Sinusitis

Sinusitis is the medical diagnosis for inflamed sinuses that can be caused by a viral or bacterial infection. When the nasal membranes become swollen, the drainage of mucous is blocked and causes pain.

There are several types of sinusitis, including these types:

• Acute Sinusitis: Infection lasting up to 4 weeks
• Chronic Sinusitis: Infection lasting more than 12 weeks
• Recurrent Sinusitis: Several episodes of sinusitis within a year

Symptoms of sinusitis can include fever, weakness, fatigue, cough, and congestion. There may also be mucus drainage in the back of the throat, called postnasal drip. Health care providers diagnose sinusitis based on symptoms and an examination of the nose and face. Treatments include antibiotics, decongestants, and pain relievers.^[10]

Pharyngitis

Pharyngitis is the medical term used for infection and/or inflammation in the back of the throat (pharynx). Common causes of pharyngitis are the cold viruses, influenza, strep throat caused by group A streptococcus, and mononucleosis. Strep throat typically causes white patches on the tonsils with a fever and enlarged lymph nodes. It must be treated with antibiotics to prevent potential complications in the heart and kidneys. See Figure 7.16^[11] for an image of strep throat in a child.

Figure 7.16

Strep Throat

If not diagnosed as strep throat, most cases of pharyngitis are caused by viruses, and the treatment is aimed at managing the symptoms. Nurses can teach patients the following ways to decrease the discomfort of a sore throat:

• Drink soothing liquids such as lemon tea with honey or ice water.
• Gargle several times a day with warm salt water made of 1/2 tsp. of salt in 1 cup of water.
• Suck on hard candies or throat lozenges.
• Use a cool-mist vaporizer or humidifier to moisten the air.
• Try over-the-counter pain medicines, such as acetaminophen.^[12]

Epistaxis

Epistaxis, the medical term for a nose bleed, is a common problem affecting up to 60 million Americans each year. Although most cases of epistaxis are minor and manageable with conservative measures, severe cases can become life-threatening if the bleeding cannot be stopped.^[13] See Figure 7.17^[14] for an image of a severe case of epistaxis.

Figure 7.17

Serious Epistaxis

The most common cause of epistaxis is dry nasal membranes in winter months due to low temperatures and low humidity. Other common causes are picking inside the nose with fingers, trauma, anatomical deformity, high blood pressure, and clotting disorders. Medications associated with epistaxis are aspirin, clopidogrel, nonsteroidal anti-inflammatory drugs, and anticoagulants.^[15]

To treat a nose bleed, have the victim lean forward at the waist and pinch the lateral sides of the nose with the thumb and index finger for up to 15 minutes while breathing through the mouth.^[16] Continued bleeding despite this intervention requires urgent medical intervention such as nasal packing.

Cleft Lip and Palate

During embryonic development, the right and left maxilla bones come together at the midline to form the upper jaw. At the same time, the muscle and skin overlying these bones join together to form the upper lip. Inside the mouth, the palatine processes of the maxilla bones, along with the horizontal plates of the right and left palatine bones, join together to form the hard palate. If an error occurs in these developmental processes, a birth defect of cleft lip or cleft palate may result.

Cleft lip is a common developmental defect that affects approximately 1:1,000 births, most of which are male. This defect involves a partial or complete failure of the right and left portions of the upper lip to fuse together, leaving a cleft (gap). See Figure 7.18^[17] for an image of an infant with a cleft lip.

Figure 7.18

Cleft Lip

A more severe developmental defect is a cleft palate that affects the hard palate, the bony structure that separates the nasal cavity from the oral cavity. See Figure 7.19^[18] for an illustration of a cleft palate. Cleft palate affects approximately 1:2,500 births and is more common in females. It results from a failure of the two halves of the hard palate to completely come together and fuse at the midline, thus leaving a gap between the nasal and oral cavities. In severe cases, the bony gap continues into the anterior upper jaw where the alveolar processes of the maxilla bones also do not properly join together above the front teeth. If this occurs, a cleft lip will also be seen. Because of the communication between the oral and nasal cavities, a cleft palate makes it very difficult for an infant to generate the suckling needed for nursing, thus creating risk for malnutrition. Surgical repair is required to correct a cleft palate.^[19]

Figure 7.19

Cleft Palate

Poor Oral Health

Despite major improvements in oral health for the population as a whole, oral health disparities continue to exist for many racial, ethnic, and socioeconomic groups in the United States. Healthy People 2020, a nationwide initiative geared to improve the health of Americans, identified improved oral health as a health care goal. A growing body of evidence has also shown that periodontal disease is associated with negative systemic health consequences. Periodontal diseases are infections and inflammation of the gums and bone that surround and support the teeth. Red, swollen, and bleeding gums are signs of periodontal disease. Other symptoms of periodontal disease include bad breath, loose teeth, and painful chewing.^[20] In 2020, the Centers for Disease Control and Prevention (CDC) reported that 42% of U.S. adults have some form of periodontitis, and almost 60% of adults aged 65 and older have periodontitis. See Figure 7.20^[21] for an image of a patient with periodontal disease. Nurses may encounter patients who complain of bleeding gums, or they may discover other signs of periodontal disease during a physical assessment.

Figure 7.20

Periodontal Disease

Because many Americans lack access to oral care, it is important for nurses to perform routine oral assessment and identify needs for follow-up. If signs and/or symptoms indicate potential periodontal disease, the patient should be referred to a dental health professional for a more thorough evaluation.^[22]

Thrush/Candidiasis

Candidiasis is a fungal infection caused by Candida. Candida normally lives on the skin and inside the body without causing any problems, but it can multiply and cause an infection if the environment inside the mouth, throat, or esophagus changes in a way that encourages fungal growth.^[23] See Figure 7.21^[24] for an image of candidiasis.

Figure 7.21

Candidiasis

Candidiasis in the mouth and throat can have many symptoms, including the following:

• White patches on the inner cheeks, tongue, roof of the mouth, and throat
• Redness or soreness
• Cotton-like feeling in the mouth
• Loss of taste
• Pain while eating or swallowing
• Cracking and redness at the corners of the mouth^[25]

Candidiasis in the mouth or throat is common in babies but is uncommon in healthy adults. Risk factors for getting candidiasis as an adult include the following:

• Wearing dentures
• Diabetes
• Cancer
• HIV/AIDS
• Taking antibiotics or corticosteroids including inhaled corticosteroids for conditions like asthma
• Taking medications that cause dry mouth or have medical conditions that cause dry mouth
• Smoking

The treatment for mild to moderate cases of candidiasis infections in the mouth or throat is typically an antifungal medicine applied to the inside of the mouth for 7 to 14 days, such as clotrimazole, miconazole, or nystatin.

“Meth Mouth”

The use of methamphetamine (i.e., meth), a strong stimulant drug, has become an alarming public health issue in the United States. A common sign of meth abuse is extreme tooth and gum decay often referred to as “Meth Mouth.” See Figure 7.22^[26] for an image of Meth Mouth.

Figure 7.22

Meth Mouth

Signs of Meth Mouth include the following:

• Dry Mouth. Methamphetamines dry out the salivary glands, and the acid content in the mouth will start to destroy the enamel on the teeth. Eventually this will lead to cavities.
• Cracked Teeth. Methamphetamine can make the user feel anxious, hyper, or nervous, so they clench or grind their teeth. You may see severe wear patterns on their teeth.
• Tooth Decay. Methamphetamine users crave beverages high in sugar while they are “high.” The bacteria that feed on the sugars in the mouth will secrete acid, which can lead to more tooth destruction. With Methamphetamine users, tooth decay will start at the gum line and eventually spread throughout the tooth. The front teeth are usually destroyed first.
• Gum Disease. Methamphetamine users do not seek out regular dental treatment. Lack of oral health care can contribute to periodontal disease. Methamphetamines also cause the blood vessels that supply the oral tissues to shrink in size, reducing blood flow, causing the tissues to break down.
• Lesions. Users who smoke Methamphetamine may present with lesions and/or burns on their lips or gingival inside the cheeks or on the hard palate. Users who snort may present with burns in the back of their throats.^[27]

Nurses who notice possible signs of “Meth Mouth” should report their concerns to the health care provider, not only for a referral for dental care, but also for treatment of suspected substance abuse.

Dysphagia

Dysphagia is the medical term for difficulty swallowing that can be caused by many medical conditions. Nurses are often the first health care professionals to notice a patient’s difficulty swallowing as they administer medications or monitor food intake. Early identification of dysphagia, especially after a patient has experienced a cerebrovascular accident (i.e., stroke) or other head injury, helps to prevent aspiration pneumonia.^[28] Aspiration pneumonia is a type of lung infection caused by material from the stomach or mouth entering the lungs and can be life-threatening.

Signs of dysphagia include the following:

• Coughing during or right after eating or drinking
• Wet or gurgly sounding voice during or after eating or drinking
• Extra effort or time required to chew or swallow
• Food or liquid leaking from mouth
• Food getting stuck in the mouth
• Difficulty breathing after meals^[29]

The Barnes-Jewish Hospital-Stroke Dysphagia Screen (BJH-SDS) is an example of a simple, evidence-based bedside screening tool that can be used by nursing staff to efficiently identify swallowing impairments in patients who have experienced a stroke. See internet resource below for an image of the dysphagia screening tool. The result of the screening test is recorded as a “fail” if any of the five items tested are abnormal (Glasgow Coma Scale < 13, facial/tongue/palatal asymmetry or weakness, or signs of aspiration on the 3-ounce water test) or “pass” if all five items tested were normal. Patients with a failed screening result are placed on nothing-by-mouth (NPO) status until further evaluation is completed by a speech therapist. For more information about using the Glasgow Coma Scale, see the “Assessing Mental Status” subsection in the “Neurological Assessment” chapter.

Enlarged Lymph Nodes

Lymphadenopathy is the medical term for swollen lymph nodes. In a child, a node is considered enlarged if it is more than 1 centimeter (0.4 inch) wide. See Figure 7.23^[30] for an image of an enlarged cervical lymph node.

Figure 7.23

Enlarged Cervical Lymph Node

Common infections such as a cold, pharyngitis, sinusitis, mononucleosis, strep throat, ear infection, or infected tooth often cause swollen lymph nodes. However, swollen lymph nodes can also signify more serious conditions. Notify the health care provider if the patient’s lymph nodes have the following characteristics:

• Do not decrease in size after several weeks or continue to get larger
• Are red and tender
• Feel hard, irregular, or fixed in place
• Are associated with night sweats or unexplained weight loss
• Are larger than 1 centimeter in diameter

The health care provider may order blood tests, a chest X-ray, or a biopsy of the lymph node if these signs occur. ^[31]

Thyroid

The thyroid is a butterfly-shaped gland located at the front of the neck that controls many of the body’s important functions. The thyroid gland makes hormones that affect breathing, heart rate, digestion, and body temperature. If the thyroid makes too much or not enough thyroid hormone, many body systems are affected. In hypothyroidism, the thyroid gland doesn’t produce enough hormone and many body functions slow down. When the thyroid makes too much hormone, a condition called hyperthyroidism, many body systems speed up.^[32]

A goiter is an abnormal enlargement of the thyroid gland that can occur with hypothyroidism or hyperthyroidism. If you find a goiter when assessing a patient’s neck, notify the health care provider for additional testing and treatment. See Figure 7.24^[33] for an image of a goiter.

Figure 7.24

Goiter

References

1.

National Institute of Neurological Disorders and Stroke. (2019, December 31). Headache information page. https://www​.ninds.nih​.gov/Disorders/All-Disorders​/Headache-Information-Page ↵.

2.

National Institute of Neurological Disorders and Stroke. (2019, December 31). Headache information page. https://www​.ninds.nih​.gov/Disorders/All-Disorders​/Headache-Information-Page ↵.

3.

Centers for Disease Control and Prevention. (2019, February 12). Concussion signs and symptoms. https://www​.cdc.gov/headsup​/basics/concussion_symptoms.html ↵.

4.

“Concussion Anatomy.png” by Max Andrews is licensed under CC BY-SA 3.0 ↵.

5.

Centers for Disease Control and Prevention. (2013, October 24). What is a concussion? [Video]. YouTube. All rights reserved. https://youtu​.be/Sno_0Jd8GuA ^↵.

6.

Centers for Disease Control and Prevention. (2019, February 12). Concussion signs and symptoms. https://www​.cdc.gov/headsup​/basics/concussion_symptoms.html ↵.

7.

Centers for Disease Control and Prevention. (2019, February 12). Concussion signs and symptoms. https://www​.cdc.gov/headsup​/basics/concussion_symptoms.html ↵.

8.

This work is a derivative of Anatomy & Physiology by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax​.org​/books/anatomy-and-physiology​/pages/1-introduction ↵.

9.

“EpiduralHeatoma​.jpg” by James Heilman, MD is licensed under CC BY-SA 4.0 ↵.

10.

MedlinePlus [Internet]. Bethesda (MD): National Library of Medicine (US); [updated 2020, Aug 17]. Sinusitis; [updated 2020, Jun 10; reviewed 2016, Oct 26]; [cited 2020, Sep 4]; https://medlineplus​.gov/sinusitis.html ↵.

11.

“Strep throat2010.JPG” by James Heilman, MD is licensed under CC BY-SA 3.0 ↵.

12.

Centers for Disease Control and Prevention. (2020, May 1). Disparities in oral health. https://www​.cdc.gov/OralHealth​/oral_health_disparities/ ↵.

13.

Fatakia A., Winters R., Amedee R. G. Epistaxis: A common problem. The Ochsner Journal. 2010;10(3):176–178. https://www​.ncbi.nlm​.nih.gov/pmc/articles/PMC3096213/   ↵ [PMC free article: PMC3096213] [PubMed: 21603374]

14.

“Epstaxis1​.jpg” by Welleschik is licensed under CC BY-SA 3.0 ↵.

15.

Fatakia A., Winters R., Amedee R. G. Epistaxis: A common problem. The Ochsner Journal. 2010;10(3):176–178. https://www​.ncbi.nlm​.nih.gov/pmc/articles/PMC3096213/   ↵ [PMC free article: PMC3096213] [PubMed: 21603374]

16.

American Heart Association. (2000). Part 5: New guidelines for first aid. Circulation, 102(supplement 1). https://www​.ahajournals​.org/doi/10.1161/circ​.102.suppl_1.I-77 ↵.

17.

“Cleftlipandpalate​.JPG” by James Heilman, MD is licensed under CC BY-SA 3.0 ↵.

18.

“Cleft palate.jpg” by Centers for Disease Control and Prevention is licensed under CC0 1.0 ↵.

19.

This work is a derivative of Anatomy & Physiology by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax​.org​/books/anatomy-and-physiology​/pages/1-introduction ↵.

20.

Bencosme J. Periodontal disease: What nurses need to know. Nursing. 2018;48(7):22–27. ↵ [PubMed: 29847424] [CrossRef]

21.

“Periodontal Disease.png” by Warren Schnider is licensed under CC BY-SA 4.0 ↵.

22.

Bencosme J. Periodontal disease: What nurses need to know. Nursing. 2018;48(7):22–27. ↵ [PubMed: 29847424] [CrossRef]

23.

Centers for Disease Control and Prevention. (2020, June 15). Candida infections of the mouth, throat, and esophagus. https://www​.cdc.gov/fungal​/diseases/candidiasis​/thrush/index.html ↵.

24.

“Human tongue infected with oral candidiasis.jpg” by James Heilman, MD is licensed under CC BY-SA 3.0 ↵.

25.

Centers for Disease Control and Prevention. (2020, June 15). Candida infections of the mouth, throat, and esophagus. https://www​.cdc.gov/fungal​/diseases/candidiasis​/thrush/index.html ↵.

26.

"Suspectedmethmouth09-19-05closeup.jpg" by Dozenist is licensed under CC BY-SA 3.0 ↵.

27.

Maine Center for Disease Control and Prevention. (n.d.). Meth mouth. https://www​.maine.gov​/dhhs/mecdc/population-health​/odh/documents/meth-mouth.pdf ↵.

28.

Edmiaston, J., Connor, L. T., Steger-May, K., & Ford, A. L. (2014). A simple bedside stroke dysphagia screen, validated against videofluoroscopy, detects dysphagia and aspiration with high sensitivity. Journal of Stroke and Cerebrovascular Diseases: The Official Journal of National Stroke Association, 23(4), 712–716.  10.1016/j.jstrokecerebrovasdis.2013.06.030 ↵. [PMC free article: PMC4019433] [PubMed: 23910514] [CrossRef]

29.

American Speech-Language-Hearing Association. (n.d.). Swallowing disorders in adults. https://www​.asha.org​/public/speech/swallowing​/Swallowing-Disorders-in-Adults/ ↵.

30.

“Cervical lymphadenopathy right neck.png” by Coronation Dental Specialty Group is licensed under CC BY-SA 4.0 ↵.

31.

A.D.A.M. Medical Encyclopedia [Internet]. Johns Creek (GA): Ebix, Inc., A.D.A.M.; c1997-2020. Swollen lymph nodes; [updated 2020, Aug 25; cited 2020, Sep 4]; https://medlineplus​.gov​/ency/article/003097.htm ↵.

32.

National Institutes of Health. (2015). Thinking about your thyroid. https:​//newsinhealth​.nih.gov/2015/09/thinking-about-your-thyroid ↵.

33.

“Struma 00a.jpg” by Drahreg01 is licensed under CC BY-SA 3.0 ↵.

Subjective Assessment

Begin the head and neck assessment by asking focused interview questions to determine if the patient is currently experiencing any symptoms or has a previous medical history related to head and neck issues.

Objective Assessment

Use any information obtained during the subjective interview to guide your physical assessment.

References

1.

Bencosme, J. (2018). Periodontal disease: What nurses need to know. Nursing, 48(7), 22-27.  10.1097/01.nurse.0000534088.56615.e4 ↵. [PubMed: 29847424] [CrossRef]

2.

Bencosme J. Periodontal disease: What nurses need to know. Nursing. 2018;48(7):22–27. ↵ [PubMed: 29847424] [CrossRef]

Sample Documentation of Expected Findings

The patient’s skin tone is appropriate for ethnicity and they are not diaphoretic. Facial movements are symmetrical. Nares are patent and no drainage is present. Uvula and tongue are midline. Teeth and gums are in good condition. Patient is able to swallow without difficulty. Trachea is midline. There is no enlargement of the lymph nodes.

Sample Documentation of Unexpected Findings

The patient has a history of asthma and uses a fluticasone inhaler daily. White patches are present on the tongue and inner buccal membranes. Dr. Smith was notified at 1530 and a new order for nystatin medication was received and administered. Patient was instructed to rinse their mouth after every use of fluticasone to prevent thrush from recurring.

Steps

Disclaimer: Always review and follow agency policy regarding this specific skill.

1.

Gather supplies: penlight, tongue blade, and nonsterile gloves.

2.

Perform safety steps:

• Perform hand hygiene.
• Check the room for transmission-based precautions.
• Introduce yourself, your role, the purpose of your visit, and an estimate of the time it will take.
• Confirm patient ID using two patient identifiers (e.g., name and date of birth).
• Explain the process to the patient and ask if they have any questions.
• Be organized and systematic.
• Use appropriate listening and questioning skills.
• Listen and attend to patient cues.
• Ensure the patient’s privacy and dignity.
• Assess ABCs.

3.

Inspect the head and facial expressions for symmetrical movement.

4.

Inspect the nose with a penlight for drainage and occlusion.

5.

Inspect the oral cavity for lesions, tongue position, movement of uvula, and oral health using a penlight.

6.

Inspect the throat and note any enlargement of the tonsils.

7.

Palpate the lymph nodes of the head and neck, including submaxillary, anterior cervical, posterior cervical, and preauricular.

8.

Ask the patient to swallow their own saliva and note any signs of difficulty swallowing.

9.

Assist the patient to a comfortable position, ask if they have any questions, and thank them for their time.

10.

Ensure five safety measures when leaving the room:

• CALL LIGHT: Within reach
• BED: Low and locked (in lowest position and brakes on)
• SIDE RAILS: Secured
• TABLE: Within reach
• ROOM: Risk-free for falls (scan room and clear any obstacles)

11.

Perform hand hygiene.

12.

Document the assessment findings and report any concerns according to agency policy.

References

1.

RegisteredNurseRN. (2017, November 27). Head and neck assessment nursing | Head to toe assessment of head neck ENT lymphatic cranial nerves. [Video]. YouTube. All rights reserved. Video used with permission. https://youtu​.be/MkqCjH-BlMo ↵.

Learning Activities

(Answers to “Learning Activities'” can be found in the “Answer Key” at the end of the book. Answers to interactive activity elements will be provided within the element as immediate feedback.)

1.

You are working as a triage nurse in a primary care clinic. You just received a phone call from a young woman who is complaining of significant discomfort related to newly diagnosed strep throat. What instructions can you provide to her to aid in symptom management in order to alleviate discomfort?

2.

You are assessing a patient’s head and neck and note the following findings. Which should be reported to the health care provider?

a.

Tongue is midline

b.

White patches noted on both tonsils

c.

Uvula raises when patient says “Ahhh”

d.

Speech is slurred

e.

Thyroid enlarged