Abnormal Findings (Chapter 13 | Head, Face, and Neck, Including Regional Lymphatics)

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Tables 13-1, 13-2, 13-3, 13-4, 13-5
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Tension Headache

Definition: headache of musculoskeletal origin, may be a mild-to-moderate, less disabling form of migraine

Location: usually both sides, across frontal, temporal, and/or occipital region of head: forehead, sides and back of head

Character: bandlike tightness, viselike, non throbbing, nonpulsatile

Duration: gradual onset, lasts 30 min. to days

Quantity/severity: diffuse, dull aching pain, mild-to-moderate pain

Timing: situational, in response to overwork, posture

Aggravating symptoms or triggers: stress, anxiety, depression, poor posture, not worsened by physical activity

Associated symptoms: fatigue, anxiety, stress, sensation of a band tightening around head, or being gripped like a vice, sometimes photophobia or photophobia

Reliving factors/efforts to treat: rest, massaging muscles in area, NSAID medication


Migraine Headache

Definition: HA of genetically transmitted vascular origin, headache plus prodrome, aura, other symptoms

Location: commonly one-sided by may occur on both sides, pain is often behind the eyes, the temples, or forehead

Character: throbbing, pulsating

Duration: rapid onset, peaks 1-2 hours, lasts 4-72 hours, sometimes longer

Quantity/severity: moderate-to-severe pain

Timing: =2 per month, last 1-3 days, =1-10 patients have weekly headaches

Aggravating symptoms or triggers: hormonal fluctuations (premenstrual), foods (e.g., alcohol, caffeine, MSG, nitrates, cocholate, cheese), hunger, letdown after stress, sleep deprivation, sensory stimuli (e.g., flashing lights or perfumes), changes in weather, physical activity

Associated symptoms: aura (visual changes such as blind spots or flashes of light, tingling in an arm, vertigo), prodrome (change in mood, behavior, hunger, cravings, yawning), nausea, vomiting, photophobia, phonophobia, abdominal pain, person looks sick, family Hx of migraine

Reliving factors/efforts to treat: lie down, darken room, use eyeshade, sleep, take NSAID early, try to avoid opioids


Cluster Headache

Definition: HA that is intermittent, excruciating, unilateral, with autonomic signs

Location: always one-sided, often behind or around the eye, temple, forehead, cheek

Character: continuous, burning, piercing, excruciating

Duration: abrupt onset, peaks in minutes, lasts 45-90 min.

Quantity/severity: can occur multiple times a day, in "clusters" lasting weeks, severe, stabbing pain

Timing: 1-2/day, each lasting 1/2 hours to 2 hours for 1-2 months; then remission for months or years

Aggravating symptoms or triggers: exacerbated by alcohol, stress, daytime napping, wind or heat exposure

Associated symptoms: ipsilateral autonomic signs: nasal congestion or runny nose, watery or reddened eye, eyelid dropping, miosis, feelings of agitation

Relieving factors/efforts to treat: need to move, pace floor



Obstruction of drainage of cerebrospinal fluid results in excessive accumulation, increasing intracranial pressure, and enlargement of the head. The face looks small compared with the enlarged cranium. The increasing pressure also produces dilated scalp veins, frontal bossing, and down cast or "setting sun" eyes (sclera visible above iris). The cranial bones thin, sutures separate, and percussion yields a "cracked pot" sound (Macewen sign)


Down Syndrome

Chromosomal aberration (trisomy 21). Head and face characteristics may include up slanting eyes with inner epicanthal folds; flat nasal bridge; small, broad, flat nose; protruding, thick tongue; ear dysplasia; short, broad neck with webbing; and small hands with single palmar crease.



Positional or deformational plagiocephaly has increased dramatically since the "Back to Sleep" campaign started in 1992 to prevent SIDS.

It is asymmetry of the cranium when seen from the top caused by a positional preference.. It is not associated with premature closing of cranial sutures, and growth of the brain proceeds normally. This can be mitigated by "tummy time," when the parent places the infant prone for awake playing. PT and helmet therapy are further treatments.



Premature closing of one or multiple cranial sutures results in a malformed head and a cosmetic deformity. mechanism involve genetic mutations coding structural proteins or growth factor receptors. Severe deformities cannot contain the brain, eyes and optic nerves inside the cranial vault, and hypoplasia of the face results, warranting surgery.


Atopic (Allergic) Facies

Children with chronic allergies such as atopic dermatitis often develop characteristic facial features. These include exhausted face, blue shades below the eyes ("allergic shiners") from sluggish venous return; a double or single crease on the lower eyelids (Morgan lines); central facial pallor; and open-mouth breathing (allergic gaping), which can lead to malocclusion of the teeth and malformed jaw because the child's bones are still forming.


Fetal Alcohol Syndrome (FAS)

Alcohol is teratogenic to the developing fetus, resulting in severe cognitive and psychosocial impairment and changes in facial and brain structure. Characteristic faces include narrow palpebral fissures, epicanthal folds and mid facial hypoplascia. May be recognizable at birth, but more so during childhood.

Fetal alcohol spectrum disorders (FASDs) include a wide range of neurologic and behavior deficits, even without facial malformations. The risk of FASDs increases with the amount of alcohol the pregnant woman drinks.


Allergic Salute and Crease

The transverse line on the nose is also a feature of chronic allergies. It is formed when the child chronically uses the hand to push the most up and back (the "allergic salute") to relieve itching and free swollen turbinates, which allow air passage.


Torticollis (Wryneck)

A hematoma in one sternomastoid muscle, probably injured by intrauterine malposition, results in head tilt to one side and limited neck ROM to the opposite side. You feel a firm, discreet, nontender mass in mid-muscle on the involved side. This requires Tx, or the muscle can become fibrotic and permanently shortened with permanent limitation of ROM, asymmetry of the head and face, and visual problems form a non horizontal position of the eyes.


Simple Diffuse Goiter (SDG)

Goiter, a chronic enlargement of the thyroid gland, is common in wide regions of the world (especially mountainous regions) where the soil is low in iodine. Iodine is an essential element in the formation of thyroid hormones.


Thyroid - Multinodular Goiter (MNG)

Multiple nodules usually indicate inflammation or a multi-nodular goiter rather than a neoplasm. However, suspect any rapidly enlarging or firm nodule. Refer all patients with a nodule for ultrasonography.


Single Nodule

Thyroid nodules are palpable in 1-5% of ambulatory care patients but can be identified in 50% of ultrasound studies. Over 95% of these are benign. Suspect any painless, rapidly growing nodule, especially a single nodule in a young person. Cancerous nodules are usually hard and fixed to surrounding structures. At increased risk are makes ages <15 y/o and >45 y/o; size >4 cm; and Hx of radiation exposure, especially in childhood.


Pilar Cyst (Wen)

This is a smooth, firm, fluctuant swelling on the cast that contains sebum and keratin. Tense pressure of the contents cause overlying skin to be shiny and taut. It is a benign growth.


Parotid Gland Enlargement

Rapid painful inflammation of the parotid occurs with mumps. Parotid swelling also occurs with blockage of a duct, access, or tumor. Note swelling anterior to lower ear lobe. Stenson duct obstruction can occur in aging adults dehydrated from diuretics or anticholinergics.


Graves Disease (Hyperthyroidism)

Increased production of thyroid hormones causes an increased metabolic rate. This is manifested by goiter and exophthalmos (bulging eyeballs). Symptoms include nervousness, fatigue, weight loss, muscle cramps, and heat intolerance. Signs include forceful tachycardia; SOB; excessive sweating; the fine muscle tremor; thin silky hair; warm; moist skin; infrequent blinking; and a staring appearance.


Myxedema (Hypothyroidism)

A deficiency of thyroid hormone means that the thyroid furnace is cold. This reduces the metabolic rate and, when severe, causes a non pitting edema or myxedema. Usual cause if Hashimoto thyroiditis. Symptoms include fatigue and cold intolerance. Signs include puffy, edematous face, especially around eyes (periorbital edema); puffy hands and feet; coarse facial features; cool, dry skin; and dry, coarse hair and eyebrows.



Excessive secretion of growth hormone from the pituitary gland after puberty creates an enlarged skull and thickened cranial bones. Note the elongated head, massive face, over-growth of nose and lower jaw, heavy eyebrow ridge, and coarse facial features.


Cushing Syndrome

With excessive secretion of adrenocorticotropin hormone (ACTH) and chronic steroid use, the person develops a plethoric, rounded, "moonlike" face, prominent jowls, red cheeks, hirsutism on the upper lip, lower cheeks and chin and acneiform rash on the chest.


Bell Pasly (Left Side)

A lower motor neuron lesion (peripheral), producing rapid onset of cranial nerve VII paralysis of facial muscles; almost always unilateral. This may be a reactivation of herpes simplex virus (HSV-1) that has been latent since childhood. Note complete paralysis of one half of the face; person cannot wrinkle forehead, raise eyebrow, close eyelid, whistle, or show teeth on the left side. Usually presents with smooth forehead, with palpebral fissure, flat nasolabial fold, drooling, and pain behind the ear. The condition is greatly improved if corticosteroids are given within 72 hours of onset.


Stroke or "Brain Attack"

An upper motor neuron lesion (central). A stroke is an acute neuralgic deficit caused by blood clot of a cerebral vessel, as in atherosclerosis (ischemic stroke), or a rupture in a cerebral vessel (hemorrhagic stroke).

Note paralysis of the lower facial muscles but also note that the upper half of the face is not affected because of the intact nerve from the unaffected hemisphere. The person is still able to wrinkle the forehead and close the eyes .


Parkinson Syndrome

A deficiency of the neurotransmitter dopamine and degeneration of the basal ganglia in the brain. The immobility of features produces a face that is flat and expressionless, "mask like," with elevated eyebrows, staring gaze, oily skin, and drooling.


Cachectic Appearance

Accompanies chronic wasting diseases such as cancer, dehydration, and starvation. Features include sunken eyes, hollow cheeks, and exhausted, defeated expression.