Head, Mouth, Nose, Throat, Neck and Regional Lymph Nodes: Kristin Clephane, MSN, RN, CPN

Head, Mouth,
Nose, Throat,
Neck and
Regional Lymph
Nodes
Kristin Clephane, MSN, RN, CPN
The Head
Skull- 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 Sutures
Facial Bone:
Only the mandible moves (TMJ)
The Head
The Head
Glands of the Head
Salivary- Three pairs of glands,

located bilaterally. (only two
palpable).
Parotid- Largest salivary gland, not

normally palpable.
Submandibular- beneath mandible.
Sublingual- floor of the mouth.
The
Neck
Conduit for passage of:
Vessels, muscles, nerves,

lymphatics, respiratory
organs (air), digestive organs
(food and fluid).
Also contains: Thyroid

Gland
Endocrine 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 Neck
Cartilage/Bones of the neck
Cricoid cartilage
In front of trachea, protects breathing.
Thyroid cartilage
Above cricoid cartilage, protects thyroid.

Adams apple.
Hyoid Bone
High, at the level of the floor of the mouth.
(Remember the vertebrae)
The Neck
Lymphatics
Lymph 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 skull
Submental - Under the chin
Submandibular 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.
Lymph Nodes
Lymphatics
Drainage:
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 Children
Fontanels- 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
Assessment
Ask patient if the have a history of:

Headaches
Onset, Location, Character, Duration, Precipitating Factors,
Alleviating Factors, Pattern, Treatment.
Head Injury
Onset, Location, Duration, Associated symptoms, Pattern,
Treatment.
Dizziness
Lightheadedness vs. Falling vs. Spinning, Onset, Associated
Factors
Neck Pain
Onset, Location, Associated Symptoms, Precipitating Factors,
Treatment.
Lumps or swelling
Recent infection/tenderness, History of: radiation, smoking, chew
tobacco, thyroid problems.
Head or neck surgery
What surgery, when, where, and outcome.
History/Subjective
Assessment
For 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 Data
Inspect and Palpate the Skull
Normocephalic normal size and shape.

Temporal Area- Palpate the temporal artery.
TMJ- palpate this joint.
Inspect the Face
Facial Structures- appropriateness to behavior and

mood.
Note symmetry
Note involuntary movements.
Note abnormal features or swelling.
Inspect and Palpate the Neck
Symmetry head midline, muscles symmetrical

ROM 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.
Inspect and Palpate the

Neck
Symmetry, ROM
LYMPH NODES
Use 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.
Lymph Nodes
If 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
Data
Trachea
Should be midline.
Slide finger from sternal notch to either side,

should be equal.
Thyroid 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 assessment
Auscultate Listen for bruit
(this is abnormal).
Link: Bruits in thyroid
Slide 13-21
Questions?
Nose, Mouth and Throat
The Nose
First 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 Sinuses
Paranasal 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 Sinuses
Only 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.
Mouth
Oral 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
Mouth
Tongue- 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 teeth
Gums (gingivae)- hold teeth in place, covered with

mucous membranes.
ThroAT
Pharynx (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 Adult
Decreased 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
Data
Nose:
Discharge
Frequent colds
Sinus pain
Trauma
Epistaxis
Allergies
Altered smell
Health History/Subjective
Data
Mouth
Sores/lesions
Sore throat
Bleeding gums
Toothache
Hoarseness
Dysphagia
Altered taste
Smoking/Alcohol
Self-Care behaviors (dentist, dentures)
Slide 16-36
Health History/Subjective Data

Additional history for
infants and children
Additional history for

the aging adult
Mouth infection
Mouth dryness
Sore throat
Tooth loss
Tooth eruption
Care of teeth, dentures
Self-care
Taste, smell
Slide 16-37
Objective DataPhysical Exam

Preparation
Positioning- sitting upright, head at eye level.
Equipment
Otoscope with short, wide-tipped nasal speculum

attachment
Penlight
Two tongue blades
Cotton gauze pad (4 4 inches)
Gloves
Long-stem light attachment for otoscope (occasionally)

(cont.)
NoseInspect and palpate
External nose
Symmetric, midline, proportional.

Any deformities?
Nasal cavity
Patent- occlude one nare at a time.

Nasal septum- Deviated?
Turbinates- Swelling? Color?
Slide 16-38

(cont.)
Sinus AreasPalpate
Frontal and maxillary

sinuses (Press gently with
thumbs)
Slide 16-39

MouthInspect
Lips- 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.
Pat Thomas, 2006.
Slide 16-40
Objective Data/Physical
Exam
Hard 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
ThroatInspection
Tonsils grading (pictured)
1+=Visible, 2+ halfway
between tonsillar pillars
and uvula, 3+ touching
the uvula, 4+ touching
each other.
Posterior pharyngeal wallwill trigger the GAG

REFLEX!! (cranial nerves
IX and X)
Stick out your tongue

should be midline. (cranial
nerve XII)
Slide
16-42
Objective Data: Mouth
Gloved 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
Questions?

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Head, Mouth,

Skull- rigid, bony box (or vault) includes bones of

Frontal, Parietal, Occipital, and Temporal

Sutures- Immovable Joints (not joined at birth to

Only the mandible moves (TMJ)

Glands of the Head

Salivary- Three pairs of glands,

Parotid- Largest salivary gland, not

Conduit for passage of:

Vessels, muscles, nerves,

Also contains: Thyroid

Endocrine gland that controls

Two major muscle groups:

Anterior triangle- in front

Cartilage/Bones of the neck

In front of trachea, protects breathing.

Above cricoid cartilage, protects thyroid.

High, at the level of the floor of the mouth.

(Remember the vertebrae)

Lymph System drains the immunologic waste products.

Lymph Node in the head and neck:

Preauricular In front of ear.

Since the lymph system drains immunologic waste,

Basically another vessel (like blood vessels).

Located throughout body, but can only be examined

Fontanels- spaces where the sutures in the skull

Covered by soft spots, will ossify (close).

Allow for growth during the first year.

Lymphoid tissue well developed at birth.

Thyroid gland enlarges during pregnancy.

Facial bones and orbits appear more prominent.

Ask patient if the have a history of:

For Aging Adult Add:

If dizziness occurs, how does it affect ADLs? Can you

For Children Add:

Inspect and Palpate the Skull

Normocephalic normal size and shape.

Inspect the Face

Facial Structures- appropriateness to behavior and

Note involuntary movements.

Note abnormal features or swelling.

Inspect and Palpate the Neck

Symmetry head midline, muscles symmetrical

Inspect and Palpate the

Use gentle circular

If any nodes are palpable,

Slide finger from sternal notch to either side,

Nose, Mouth and Throat

First segment of respiratory system.

Nasal Cavity- Extends back over the roof of the mouth,

Septum- Divides the nose, most common site of nose

Turbinates- Three bony projections that increase surface

Meatus- cleft in the turbinates, allows drainage.

Paranasal Sinuses- air-filled pockets in the head.

Lined with mucous membranes.

Only two pairs of sinuses are easily assessable:

Sinuses mature and develop as we age, only

Oral Cavity- contains teeth, tongue, salivary

Hard Palate- In front part of mouth (anterior)