Head and Neck

Core Concepts

Anatomy and landmarks: what you are examining

• Skull: The cranium is formed of fused bones — frontal (forehead), parietal (top/sides), temporal (sides, around ears), occipital (back/base) — meeting at suture lines. Facial bones include the maxilla (upper jaw), mandible (the only movable skull bone), zygomatic (cheekbones), nasal, and orbit bones. The temporomandibular joint (TMJ) is just in front of the ears.
• Paranasal sinuses: Air-filled spaces in the frontal, maxillary, ethmoid, and sphenoid bones that lighten the skull and resonate the voice; they commonly become infected (sinusitis).
• Neck: The neck is organized into anterior and posterior triangles bounded by the sternocleidomastoid and trapezius muscles. Midline structures include the trachea and thyroid gland (just below the laryngeal prominence), with the carotid arteries along the sides; the cervical spine supports the head.
• Lymph nodes: Chains of small filters run through the neck — preauricular, postauricular, occipital, submandibular/submental, cervical, and supraclavicular — draining the scalp, face, ears, mouth, and throat.

Inspection: look before you touch

• Head: Size, shape, symmetry; scalp for lesions, scaling, or injuries; hair distribution and texture.
• Face: Symmetry — ask the person to smile, raise eyebrows, and close the eyes tightly; note drooping or flattening of the nasolabial fold (a stroke-screening clue, though many causes exist), plus expression, skin color, lesions, swelling, and involuntary movements.
• Neck: Symmetry; visible masses; trachea position (should be midline); neck vein distention (at 45 degrees, jugular veins should not bulge — distention suggests fluid overload); range of motion (chin to chest, look up, turn side to side).
• Cranial nerve screening: CN V (facial sensation, jaw clenching), CN VII (facial movements), CN XI (shoulder shrug, head turn), CN XII (tongue protrusion).

Palpation: feel the details

• Skull: Gently palpate for tenderness, depressions, or masses; the TMJ as the person opens and closes the mouth (note clicking or pain).
• Sinuses: Press gently over the frontal and maxillary sinuses; tenderness suggests congestion.
• Lymph nodes: Using the finger pads, gently roll the nodes in each chain, comparing sides, and note size, consistency, mobility, tenderness, and warmth. Small, soft, mobile, tender nodes usually accompany infection; hard, fixed, painless nodes warrant prompt referral — though only a provider interprets what enlarged nodes mean. Document objectively and report.
• Trachea: Check midline with a finger in the suprasternal notch; deviation is significant and should be reported immediately.
• Thyroid: Standing behind the person, locate the isthmus just below the cricoid cartilage, then palpate both lobes as the person swallows (the gland rises with swallowing). A normal thyroid is often barely palpable; enlargement (goiter) or nodules are documented and referred. Technique varies by institution — follow your program's taught method.

Auscultation: listen to the vessels

Auscultate the carotid arteries with the bell as the person holds their breath. A bruit is an abnormal "whooshing" sound from turbulent flow through a narrowed vessel — a finding that warrants reporting. Safety rule: never palpate both carotid arteries at once, and never press hard on one — this can reduce blood flow to the brain. A thyroid bruit may be sought when a goiter is present.

Common findings and what they may suggest

Findings are clues, not diagnoses — a provider interprets them:

• Enlarged lymph nodes: most often infection (dental, ear, throat, scalp) — tender, mobile, soft; hard, fixed, non-tender nodes warrant further evaluation.
• Goiter (enlarged thyroid): may relate to iodine status or thyroid dysfunction; the provider evaluates function.
• Facial asymmetry: could be stroke (often sudden), Bell's palsy, or congenital — sudden facial weakness is an emergency until proven otherwise.
• Tracheal deviation: away from a collapsed lung or toward a mass — an urgent finding; report immediately.
• Nuchal rigidity (stiff, painful neck with resisted flexion): a possible sign of meningeal irritation — an emergency finding.
• Jugular vein distention: suggests fluid overload — connect with cardiac and fluid assessments.

Population and age considerations

• Infants: The head is large relative to the body; fontanelles are assessed — a bulging fontanelle is an emergency finding (possible increased intracranial pressure), a sunken one suggests dehydration. Head circumference is plotted at well-child visits.
• Older adults: Neck range of motion often decreases (arthritis); skin thins and dries; thyroid nodules become more common with age.
• Communication: Respect preferences about touch and proximity — ask before palpating, explain as you go, and stop any maneuver that causes pain.

Documentation

Document in head-to-toe flow: head (inspection, palpation, hair/scalp), face (symmetry, CN screening), neck (range of motion, masses, trachea midline, thyroid, lymph nodes, vascular findings). Record objectively — "1 cm firm, non-tender, mobile node at the left anterior cervical chain," not "swollen glands." Normal findings can be summarized ("head normocephalic, atraumatic; face symmetric; neck supple"); abnormal findings get full description, and anything urgent is reported and documented immediately.

Common Confusions