7.7 Face, Neck, and Cranium

Assessment of the face, neck, and cranium involves inspection, palpation, ROM, and MMT. This assessment is best performed with the client sitting upright on the exam table. However, depending on the client’s situation, it can be performed when they are sitting in a chair/wheelchair or lying in bed.

Inspection of the Head 

The head is observed and noted for size described as symmetrical in shape and normal size described as normocephalic. The head may appear small (microcephalic) or large (macrocephalic) with follow-up based on the history and assessment.

Steps for inspecting the head (including the face, neck, and cranium) include:

1. Inspect the face for color, symmetry, swelling, masses, and deformities with a focus on the muscles, bones, and joints.

• • Normally, the face has no discolorations such as erythema and is symmetrical with no swelling, masses, or deformities. Describe the appearance and location of any discoloration, swelling, masses, and deformities.

2. Inspect the anterior, lateral, and posterior sides of the neck and cranium (as well as the superior side of the cranium). Depending on the reason for assessment, it may be appropriate to request permission to move the client’s hair so that you can directly observe the cranium.

• • Normally, the head is upright and centered and the cranium and the neck are symmetrical with no masses, swelling, deformities, or discolorations. Describe the appearance and location of any asymmetry, masses, swelling, deformities, and discolorations (these will be further assessed with palpation).

3. Note the findings.

• • Normal findings might be documented as: “Client’s head is upright and centered. No masses, swelling, deformities, or discoloration on the head, face, and neck.”
  • Abnormal findings might be documented as: “Client’s face has swelling over the right zygomatic (cheekbone) area with bluish-purple discoloration.”

Palpation

Steps for palpating the cranium, face, and neck include:

1. Palpate the temporomandibular joint (where the maxilla and mandible meet anterior to the tragus). Do both sides at the same time and place two to three finger pads on each side and move in a circular motion in two to three areas. Then, use dorsa of hands and palpate the posterior side of neck for temperature. The rest of the facial structures are normally not palpated unless the client has indicated a concern or has experienced a physical injury.

• • Normally, the temperature is equal bilaterally, muscles are firm to touch, and no pain is felt on palpation.

2. Palpate down the cervical spine and the paravertebral muscles on the posterior side of the neck from inferior to the occipital bone (C1) down to C7 (see Video 1). Then, palpate down the trapezius muscles followed by the sternomastoid muscles. Ask the client if they have any pain/tenderness.

• • Normally, the cervical spine and muscles are symmetrical with no pain, masses, swelling, deformities, or paravertebral muscle spasms. The description and location of abnormal findings should be noted. Description of masses and swelling may include size and consistency (soft or hard).

3. Note the findings.

• • Normal findings might be documented as: “Temperature warm to touch and equal bilaterally with no pain on temporomandibular joint. Cervical spine and muscles are symmetrical with no pain, masses, swelling, or deformities noted on palpation.”
  • Abnormal findings might be documented as: “Client noted pain as a 6/10 upon palpation of the cervical spine. Swelling palpable from C6–7.”

Video 1: Palpation of spinous processes and paravertebral muscles from C1 to C7 [0:43]

Range of Motion (ROM)

ROM related to the face is focused on the temporomandibular joint and includes vertical and lateral motions and protraction and retraction. ROM of the neck involves flexion, extension, lateral bending, and rotation (see Table 7.4 for normal ranges). For cervical spine ROM, you will assess the gross ROM, which is the cumulative ROM of all of the spinal segments together.

While performing the assessment, observe the ROM, quality of the movement, listen for crepitus, and ask the client about the presence of pain.

While demonstrating the movements yourself, the steps in assessing ROM of the temporomandibular joint and the neck are:

1. Ask the client to open and close their mouth (vertical motion). Then, place your index and middle fingers on the temporomandibular joints on both sides of the face and ask them to repeat the movement
   • Normally, there should be no pain and the temporomandibular joint should open and close smoothly. Sometimes, you may hear and/or feel a click (clunk) of the jaw. This is usually not of concern unless associated with pain and affecting the ability to chew food.
2. Ask the client to perform neck flexion by attempting to touch their chin to their chest and bring it back to neutral position.
3. Ask the client to perform neck extension by gently tilting their head back and bring it back to neutral position.
4. Ask the client to perform neck lateral bending by tilting their head to the right, back to neutral position, and then to the left (i.e., “attempting to touch their ear to their shoulder”).
5. Ask the client to perform neck rotation by turning their head to the right, back to neutral position, and then to the left.
6. Note the findings.

• • Normal findings might be documented as: “Client’s temporomandibular joint and neck has full ROM, movements of joints are smooth and symmetrical with no obvious misalignments, no crepitus or pain noted.”
  • Abnormal findings might be documented as: “Client’s neck has limited ROM in flexion with no crepitus. Pain noted as a 3/10 while flexing.”

NOTE: See Video 2 for ROM of the neck.

Video 2: ROM of neck [0:58]

Manual Muscle Testing (MMT)

Assess MMT after ROM. Explain the procedure before applying force. Perform MMT on each joint bilaterally. Grade the resistance according to the institution’s grading scale (e.g., MRC) or just describe it and note whether it is equal bilaterally. Keep in mind that MMT of the neck also provides information about the functioning of cranial nerve XI (spinal accessory nerve) and whether it is innervating the muscles.

MMT of the face, neck, and cranium is focused only on the neck and is typically performed with the client in sitting position. The steps involve:

1. Begin with the client’s head in a neutral position looking straight ahead. To perform cervical/neck flexion, stand slightly lateral to the client, place one hand on the thoracic spine for stability and the other on the client’s forehead, then ask them to bend their neck bringing their chin to their chest while you apply force with your hand on their forehead. Ask them to resist your force. Release the force and ask them to return their head to neutral. Note if the client tries to move their shoulders or thoracic body during the procedure.
2. Next, place one hand on the posterior occipital bone and the other on the client’s shoulder for stability. To perform neck extension, ask the client to look up to the ceiling to extend the cervical spine, while applying force with the hand on the occipital bone. Ask them to resist your force. Release the force and ask them to return their head to neutral. Note if the client tries to use their back during the procedure.
3. Move in front of the client. For stability, place one hand on their right shoulder and the other on the client’s head above the left ear over the temporal bone structures. To perform lateral bending, ask the client to touch their left ear to their left shoulder, while you apply force to the movement. Ask them to resist your force. Release the force and ask them to return their head to neutral. Repeat the procedure on the opposite side. Note if the client tries to flex the lateral thoracic spine during the procedure.
4. To perform rotation, place one hand on the right shoulder for stability and the other on the lateral side of the client’s face with fingers pointing toward the temporal bone structures. Ask the client to look left to rotate the cervical spine while you apply force. Ask them to resist your force. Release the force and ask them to return their head to neutral. Repeat the procedure on the opposite side. Note if the client tries to rotate the thoracic spine during the procedure.
5. Note the findings.

• • Normal findings might be documented as: “full resistance equal bilaterally on all neck ROM with no pain.”
  • Abnormal findings might be documented as: “partial resistance equal bilaterally on all neck ROM with mild pain.”

NOTE: See Video 3 for MMT of the neck.

Video 3: MMT of the neck [1:34]

Activity: Check your Understanding 

References

Brown, S. (2018). “Don’t touch my hair”: Problematizing representations of Black women in Canada. Africology: The Journal of Pan African Studies, 12(8), 64-85.

Johnson, T., & Bankhead, T. (2014). Hair it is: Examining the experiences of Black women with natural hair. Open Journal of Social Sciences, 2, 86-100. https://doi.org/10.4236/jss.2014.21010

Luttgens, K. & Hamilton, N. (1997). Kinesiology: Scientific Basis of Human Motion, 9th Ed., Madison, WI: Brown & Benchmark