Examine the lymph nodes. All the chains (as indicated in Chapter 9, The Head and Neck) must be examined. Small (0.75- to 1.5-inch [2- to 4-mm]), movable, nontender, discrete nodes are commonly found. Warm, tender nodes are usually indicative of infection.

Inspect the shape of the head.

Palpate the sutures in the 1- to 3-year-old child. Check for the fontanelles. The posterior fontanelle frequently closes soon after the neonatal period. The anterior fontanelle may close as early as 8 months of age or may remain open until 2 years of age. Persistence of the anterior fontanelle past 2 years of age may be a sign of an underlying disorder. The most common problem associated with failure of the anterior fontanelle to close is hypothyroidism;increased intracranial pressure must also be considered in these children.

Palpate over the maxillary sinuses in children older than 2 years. Tenderness may indicate sinusitis.

Inspect the area of the parotid glands. Localized swelling can best be detected by telling the child to look up to the ceiling while he or she is seated. Note any swelling below the angle of the jaw. Palpate the area. An enlarged parotid gland often pushes the lobe of the ear away from the side of the head; this can be seen when the child is observed from behind.

Inspect the size and shape of the neck. Check for a thyroglossal duct cyst. The child in Figure 24-41 has a midline thyroglossal duct cyst.

Palpate the anterior and posterior triangles for lymphadenopathy as in adults. Anterior cervical adenopathy is associated with inflammation of the sinuses, ears, teeth, or pharynx. Group A beta-hemolytic streptococcus is an important cause of pharyngitis in children aged 3 years and older, and can lead to rheumatic fever or postinfectious glomerulonephritis. In predicting a positive bacterial throat culture, the most important diagnostic sign is reported to be tender anterior cervical lymphadenopathy.

Palpate the sternocleidomastoid muscle.

Inspect the location of the trachea. Is it midline?

Palpate the thyroid gland. This is usually best done by using your thumb and index finger to feel for the gland while the child is in a supine position.

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