2. Embryological
Development
• Rapid growth of the head and
brain begins in 5th week in
utero
• From the 5th to 8th week in
utero, the head is the fastest
growing part of the body and
makes up 50% of the body at 8
weeks gestation
• 13th week – ossification of the
cranium begins; hair patterns
on the scalp develop
• Second and third trimesters –
head becomes proportional to
the body
6. Development of
the face- 6th
week (24-38
days)
• 2 medial nasal processes fuse
• Tip of the nose, columella, philtrum, primary palate (4 maxillary incisors)
• Maxillary process + medial nasal processes Lateral aspect of upper lip, cheek, remaining
maxillary teeth, secondary palate
• Maxillary process + lateral nasal processes
• Nasolacrimal duct
• Lateral nasal processes
• Ala of the nose
7. Cleft Lip and Palate 4th-12th
week
• Cleft lip
• Failure of fusion of maxillary process with median nasal process in early
gestation
• Occurs during 6th week of gestation (handbook says 4th)
• 2 Males : 1 Female
• 1:2800 per CDC
• Cleft palate
• Roof of mouth does not close, leaves an opening that can extend into
the nasal cavity
• 5-6th week- 1 palate forms- intermaxillary segment from fused
median nasal processes
• 6-12th week 2 palate forms- fused palatal shelves from maxillary
processes
• 12th week- all 3 processes fuse- 1 palate and 2 palatal shelves
• 2 Females : 1 Male
• 1:1700 per CDC
• Environmental causes: maternal cigarette and alcohol use, folic acid
deficiency, corticosteroid use, anticonvulsants drugs
• 50% associated with a syndrome
8. Growth of the Skull
• Normal growth depends on placental function,
familial and hereditary factors, growth potential
in the uterus, optimum nutrition during
pregnancy and early childhood
• Contour of cranium
• Affected by fetal position in utero and delivery
• If growth is inadequate, then brain development
is impacted
• Calvarium follows neural growth curve
• Cranial base between neural and general growth
curve.
9. Growth of the skull = Cephalocaudal Gradient
• Newborn infant: head is ¼ of body length and 1/3 of body weight
• Adult: head is 1/8 of body length and 1/10 of body weight
• Birth to 18 months: head exceeds chest circumference by 1 to 2 cm
• 18 months: chest exceeds head size by 5 to 7 cm
11. Anatomy of Neonate Skull
• Sutures: present at birth and begin to close soon after birth
• Fontanels: sagittal, sphenoidal, mastoid, anterior, and posterior
• Only the anterior and posterior fontanels can be palpated
• Posterior fontanel should close by 2 months old
• Anterior fontanel closes between 9 to 18 months old
13. Anatomy of Skull/Vertebral Column
• Cranium is supported by first
cervical vertebra, aka the atlas
• The atlas rests on the second
vertebra, aka the axis
• The atlas and the axis form the
rotational bones of the skull
15. Anatomy – Muscles
• Connections between the
muscular fascia and the facial
orifices control facial
expressions: smiling, raising
eyebrows, etc
• Superficial and deep muscles of
neck support pivotal rotation of
head
• Sternocleidomastoid muscle is
the largest neck muscle: turns
head side to side
• Trapezius muscle supports side
to side head movement and
shoulder movement
16. Anatomy - Airway
• Trachea extends from larynx to
bronchi beneath the sternum
• More mobile and more deeply
recessed in the vertebral muscles
in infants and children
• Remember if child vomiting in
chair, roll to LEFT because right
bronchi shorter and higher risk of
aspiration
• Lucky you if you’re a right-handed
operator
• Unlucky if you’re Anyen
17. Airway- Aspiration
• During mild/moderate sedation, protective reflexes are in place, so aspiration is
unlikely
• If aspiration is suspected
• Lower head below chest
• Turn patient to the right
• Right is usually the affected side due to angle of bronchus
• This will protect left side, and mortality is lower if only one side affected
• After vomiting evaluate O2 saturation and auscultate lungs for wheezing, crackles
and rales
• If aspiration is suspected, transfer patient to ED
19. Anatomy: Thyroid
• Anterior middle region of the neck below the larynx; 5th
or 6th tracheal ring
• Two lobes joined by and anterior isthmus
• Made of tiny follicles containing thyroglobulin which
binds with iodine in thyroid synthesis
• 150 to 200 mcg of iodide is sufficient for producing
enough thyroid hormone
• Secretes thyroxine into the bloodstream which
promotes normal growth
• Lingual thyroid
• Rare developmental lesion
• Ectopic thyroid tissue on tongue
• Located midline base of tongue
• 33% hypothyroidism
20. Anatomy: Parathyroid
• Four parathyroid glands are on the posterior, or dorsal,
side of the thyroid
• They secrete parathyroid hormone which regulates
calcium metabolism
• DiGeorge syndrome – abnormal development of
parathyroid gland caused by chromosome deletion 22q11;
also includes heart defects and facial abnormalities
• CATCH 22
• Cardiac defects
• Abnormal facies
• Thymic hypoplasia
• Cleft palate
• Hypocalcemia
21. Anatomy:Vasculature
• Carotid arteries:
• External carotid – supplies head,
face, neck
• Internal carotid – supplies the
cranium
• Subclavian and jugular veins – drain
blood from the cranium
• Thyroid arteries – perfuse the thyroid
and parathyroid
22. Head and neck
Assessment
includes:
History and Information gathering
Assessing the head for size, shape, and symmetry
Assessing fontanels and sutures
Evaluating head control
Assessing the trachea and thyroid gland
Proceed from the head down to the neck so as not
to miss anything!
23. Assessment – Information Gathering
• Vaginal or cesarean birth; prolonged labor, vacuum assisted delivery;
respiratory distress at birth
• History of hyperthyroidism, thyroid disease, gestational diabetes
• History of maternal or neonatal infections
• Early Childhood – history of falls, neck pain or stiffness, head trauma
• Middle childhood – history of headache, head injury; use of helmet
for bike or skateboard
• Adolescence – headaches or head injury; blurred vision; weight loss
or gain; use of helmet and other protective sports equipment
24. Measuring
circumference
• Use flexible measuring tape and place
around head just above eyebrows and
around the occipital prominence
• Age 2 or younger: measure head
circumference if concerned about neurologic
or developmental health issues
• Circumference estimates brain volume which
correlates to neurologic and developmental
functions
25. Circumference
• Large head circumference:
• Hydrocephalus
• Brain tumor
• Cerebral gigantism
• Neurofibromatosis
• Hemorrhage
• Autism
• Small head circumference:
• Craniostenosis
• Microcephaly
• Prenatal exposure to alcohol,
cocaine, and certain
infections
26. Assessment of Symmetry
• Observe symmetry of head from different angles
• Part the child’s hair to assess for lesions or masses
• Minor asymmetry in infants under 4 months is normal
• Flat occiput:
• Too much time spent in supine position
• Also noted in Down Syndrome patients
• Significant asymmetry: premature closure of sutures
• Deformational plagiocephaly
• Lateral and central side of occiput; prevented by
varying the head position when putting an infant
down to sleep and having supervised tummy time
27. Craniosynostosis
• Premature fusion of growth arrest
at one or more cranial sutures
• Metopic
• Coronal
• Sagittal
• Lamboid
• Causes problems with normal brain
and skull growth
• Pressure increase inside the
cranium
• 1: 2,100- 2,5000 births
• Syndromes: Crouzon, Apert’s
29. Palpation of Skull
• Sutures feel like prominent ridges between cranial bones
• Craniotabes – slight give in the underlying bone due to osteroporosis,
mainly the occipital and parietal bones
• Sometimes found in normal infants
• Can be due to increased cranial pressure (hydrocephaly)
• Syphilis
• Rickets
• Down syndrome: separated sagittal suture
• Beckwith-Wiedemann: prominent metopic ridge
30. Palpate Fontanelles
• Anterior fontanelle should be soft,
flat, pulsatile in infants up until 18
months
• Bulging is due to increased
intracranial pressure:
• Head injury
• Meningitis
• neoplasm
• Depressed due to dehydration
• Decrease in CSF
• Down syndrome: enlarged anterior
fontanelle; palpable sagittal
fontanelle
• Enlarged posterior fontanelle:
hypothyroidism
31. Measure anterior fontanelle
• Should be 1 to 5 cm in length and width up until 9 to 12 months old
• Abnormally large or small anterior fontanelle:
• Down syndrome
• Bone growth disorder
32. Percuss Parietal Bones
• Tap your index finger on each
parietal bone
• Percussion should produce a
“cracked pot” sound (Macewen’s
sign) in normal infants before
sutures close
• In older children, Macewen’s sign
means separation of sutures:
• Increased cranial pressure
• Encephalopathy
• Brain tumor
• Dull sound- hydrocephalus or brain
abscess
33. Inspection of Face
• Assess for symmetry of facial features, ears, and facial movements
• Observe smile, laugh, facial creases, facial wrinkles
• Injury at birth to brachial plexus – paralysis of arm and shoulder
• Injury at birth to facial nerve – asymmetrical nasolabial folds and
facial expression
• Disproportionate features, frontal bossing of forehead, small or low
set ears – may all indicate a genetic abnormality
34. Assessment of Neck
• Observe infant’s ability to hold neck upright if 4 months or older
• Head lag in 6-month-old indicates cerebral palsy or other
developmental issues with muscle tone
• Rhett syndrome- floppy baby
• Check range of neck motion; should not cause pain
• Pain to resistance and flexion: meningeal irritation
• Lateral resistance to movement: torticollis or injury to sternocleidomastoid
muscle
35. Assessment of Neck
• Palpate lymph nodes
• Mononucleosis- EBV, generalized mononucleosis
• Inspect for masses, webbing, extra skin folds, distended veins
• Turner syndrome: Webbing and extra skin
• Down syndrome: excessive and lax skin
• Thyroglossal duct cyst: swelling at midline above thyroid cartilage (in
young infant)
• Cervical lymphadenopathy: bacterial or viral infection; tonsillitis
• Parotid swelling: mumps, sialolith
• Enlarged occipital nodes: rubella or roseola infantum
• Vein distention usually accompanies labored respirations
36. Palpate Trachea
• Place thumb on one of the trachea and index finger on the other
• Slide the fingers up and down while the neck is slightly
hyperextended
• Any shift in trachea can indicate serious lung problems
37. Palpate Thyroid Gland
• Thyroid disease symptoms in children: hypotonia, lethargy, distended
abdomen, enlarged tongue
• In children thyroid gland may not be palpable until child is school-
aged
• Stand behind the child and place fingers at the base of the neck
• Gland rises as child swallows
• Enlarged thyroid:
• Goiter
• Lymphatic
• Thyroiditis
38. Examine Hard/Soft
Palate and Tonsils
• Mallampati- visual
assessment to predict ease
of endotracheal intubation
• Class I- soft palate,
uvula, pillars visible
• Class II- soft palate,
uvula, fauces visible
• Class III- soft palate,
base of uvula visible
• Class IV- only hard
palate visible
41. Examination Following Trauma
• Cranial nerve examination
• III, IV, VI- eye movement
• V-check muscles of mastication
• VII- smile/frown
• X-stick tongue out
• Thorough head and neck exam
• Document all soft tissue injuries
• Lacerations
• Abrasions
• Battle sign= mastoid hematoma
• Posterior cranial fracture
• Racoon sign= orbital hematoma
• Anterior cranial bone fracture
42. Examination Following Trauma
• Condylar fracture common in children due to
blow to chin
• Signs of bone fracture:
• Change in occlusion
• Inability to close
• Step on mandibular border
• Vertical laceration on alveolus
• Facial asymmetry
• Pain on mastication
• Sublingual hematoma
• Contusions
• Most often associated with underlying
bone fracture
44. Diagnostic Procedures
• Computed Tomography (CT) – used in head injury cases; diagnosis of
fractures
• Magnetic resonance imaging (MRI) – diagnosis of tumors or skull
malformations
• Skeletal radiography – evaluation of craniosynostosis
• Towne’s view=mid-face fracture
• Water’s view= orbital floor
• Ultrasound – diagnosis of abnormal neck mass
• Thyroid function test – diagnosis of thyroid disease
45. References
Engel. Mosby’s Pocket Guide Series: Pediatric
Assessment, 5th Edition. Mosby. St. Louis, 2006.
Duderstadt, KG. Pediatric Physical Examination:
An Illustrated Handbook, 2nd Edition. Elsevier.
St. Louis, 2014.
AAPD 5th Edition Handbook
Screenshot photos from the world wide web
Arch 1 and 2- treacher Collins; hemifacial microsomia
Handbook CL 1:700, CL with or without CP 1:300-500; CP 1:1000
Allow bones to flex to pass through birth canal
Access hydration- sunken in, doesn’t feel firm
Palpate trachea during exams
Fish, seaweed, shrimp
Hypoparathyroidism
Low serum calcium
Increased serum phosphate
Enamel hypoplasia
Hypodontia
Shortened roots with delayed apical closure
Increased risk of candidiasis
Tummy time- start day they come home from hospital
Peritonsillar abscess
Uvula deviation away from affected side
Sore throat, trouble swallowing, ipsilateral ear pain, drooling, bad breath, muffled voice, trismus
Most common deep neck infection in children and adolescents
Group A beta hemolytic strep
