Procedure 13-1 CONDUCTING EXTRAORAL ASSESSMENTS

Steps from Fehrenbach MJ, Herring SW: Illustrated anatomy of the head and neck, ed 3, St Louis, 2007, Saunders. Figures courtesy Dr. Margaret Walsh, University of California–San Francisco.

EXTRAORAL REGIONS	STEPS	RATIONALES
Overall evaluation of the face, head, and neck including skin (Figure 13-1)	Visually observe symmetry and coloration of face and neck.	Allows the clinician to check for signs of nutritional deficiency and signs of systemic disease, possible asymmetry from neoplasm, or abnormal growth and development. Be aware that signs of physical abuse often occur in the head, face, and neck region.

Parietal and occipital regions, including scalp (Figure 13-2, A), hair, and occipital nodes (Figure 13-2, B) Visually inspect the entire scalp by moving the hair, especially around the hairline, starting from around one ear and proceeding to the other ear. Standing behind, have the client bend the head forward, and bilaterally palpate the occipital nodes. Allows the clinician to inspect the scalp, where many lesions may be hidden by hair, and inspect the occipital nodes to check for tender, enlarged nodes or masses indicating local or systemic involvement. These nodes drain the area and may indicate a disease state in that area. Temporal region, including auricular nodes (Figure 13-3, A and B) and ears (Figure 13-3, C) Standing near the client on one side then the other, visually inspect and bilaterally palpate the auricular nodes and the scalp and face around each ear. Visually inspect and palpate each ear. Allows the clinician to check for tender, enlarged nodes or massing indicating local or systemic involvement. These nodes drain the areas around the ear and may indicate a disease state in that area. Also allows for inspection of the ear itself to check for infection or skin cancer. Frontal region, including forehead and frontal sinuses (Figure 13-4) Visually inspect and use bilateral palpation of the forehead, including the frontal sinuses. Allows the clinician to check for any changes in the frontal bone and sinuses by checking for masses, tenderness, and increase skin temperature. Orbital region, including the eyes (Figure 13-5) Visually inspect the eyes and their movements and responses. Allows the clinician to check for any changes in the cranial nerves that serve the eyes, which may first exhibit as changes in the eye’s movement, constriction of the pupil, or changes in the visual acuity or field. Nasal region, including the nose (Figure 13-6) Visually inspect and use bilateral palpation for the nasal region, starting at the root of the nose and proceeding to its tip. Allows the clinician to assess for symmetry of the nose and for any signs of respiratory conditions. Infraorbital and zygomatic regions, including the muscles of facial expression (Figure 13-7, A), facial nodes (Figure 13-7, B), maxillary sinuses (Figure 13-7, C), and temporomandibular joints (TMJs) (Figure 13-7, D and E) Visually inspect the under eye and cheek areas, noting the use of the muscles of facial expression. Visually inspect and use bilateral palpitation of the facial nodes by moving from infraorbital region to the labial commissure and then to the surface of the mandible. Visually inspect and use bilateral palpitation of the maxillary sinuses. Gently place a finger into the outer portion of the external acoustic meatus. To access the TMJ and its associated muscles, use bilateral palpitation and ask the client to open and close the mouth several times. Then ask client to move the opened jaw left, then right, and then forward. Ask the client if they experienced any pain or tenderness. Note any sounds made by the joint. Checks for a lack of expression, which may indicate a change in the cranial nerve that serves the facial muscles. Also checks the maxillary sinus for tenderness and increased skin temperature. Allows the clinician to assess for temporomandibular disorders (TMDs). Buccal region, including the masseter muscle (Figure 13-8, A) and parotid salivary glands (Figure 13-8, B) Standing near the client on each side, visually inspect and use bilateral palpation of the masseter muscle and parotid gland by starting in front of each ear and moving to the cheek area and down to the angle of the mandible. Place the fingers of each hand over the masseter muscle and ask client to clench the teeth together several times. Allows the clinician to check for tender, enlarged nodes or masses indicating local or systemic infection. These nodes drain the area of the cheek and may indicate a disease state in that area. Also allows the clinician to check the masseter muscle for development and that the parotid glands are free of tenderness and enlargement. Mental region, including the chin (Figure 13-9) Standing near the client on each side, visually inspect and use bilateral palpitation of the chin. Allows the clinician to detect enlargement or masses, as well as any abnormal growth of soft tissue or bone, surface lesions, and tenderness. Anterior and posterior cervical regions, including sternocleidomastoid muscle (SCM) and associated nodes (Figure 13-10) With the client looking straight ahead, use manual palpitation with two hands on each side of the neck to assess the superficial cervical nodes. Start below the ear and continue the whole length of the SCM surface to the clavicles (see Figure 13-18, A). Then have the client tilt the head to the side and palpate the deep cervical nodes on the underside of the anterior and posterior aspects of the SCM. Allows the clinician to check for enlarged nodes or masses indicating local or systemic disease. Submandibular and submental triangle regions, including submandibular and sublingual salivary glands and associated nodes (Figure 13-11) Standing slightly behind the client on eac/>