HEAD and NECK Dr Sham A. Cader
Method Of Exam • Inspect the head for size • Feel for the skull for integrity and evenness • Evaluate the hair for texture and hair loss. • Inspect and palpate the scalp. • Normal: • The head is symmetrical. Size varies with age and • body stature. • Male pattern hair loss is common. • Minor undulations are normal for the skull.
Skin • Skin exam is not separate from the rest of the physical examination examine the patient in good lighting. • Inspect and palpate skin for the following: • Color: Contrast with color of mucous membrane.
Texture • Turgor: Lift a fold of skin and note the ease with which it moves (mobility) and the speed with which it returns into place • Moisture • Pigmentation • Lesions • Hair distribution • Warmth: Feel with back of your hand
THE EYE • SYMPTOMS: • SUDDEN LOSS of VISION: Potential Causes • AMAUROSIS FUGAX: Temporary, monocular, ischemic blindness. Painless Caused buy ipsilateral Carotid stenosis or embolization of the retinal artery. • RETINAL DETACHMENT: Flashing lights, floating halos, and blurry vision before the blindness is indicative of retinal detachment. • UVEITIS: Inflammation of uveal tract -- iris, ciliary body, and choroid. Always painful.Associated with multiple diseases: connective tissue diseases, histoplasmosis, sarcoidosis, tuberculosis
GRADUAL LOSS of VISION • CATARACTS: Opacities of the lens, occurring with age. • GLAUCOMA: Increased intraocular pressure. It is the most common reason for loss of vision over age 50. • MACULAR DEGENERATION: Secondary to Diabetes, and expected to cause visual blindness. • Diabetic Retinopathy. • OPTIC NERVE COMPRESSION: Caused by an intracranial neoplasm, or pituitary adenoma. • OPTIC NEUROPATHY (Optic Neuritis):Multiple Sclerosis, and drugs such as Ethambutol, Methanol, can all cause optic neuritis and gradual blindness.
PRESBYOPIA: Gradual loss of ability of Accommodation for near-vision, occurring with age. • CORTICAL BLINDNESS: Infarct of the Occipital Lobe can lead to cortical blindness. Patient will have binocular blindness, but will retain the pupillary light reflex which is unaffected • DIPLOPIA: Double vision. • Monocular Diplopia: Should suggest corneal or lens problem. • Binocular Diplopia: Indicative of cranial nerve palsy or ocular muscle problems, or a brainstem problem. • Myasthenia Gravis (MG): Diplopia without pain is often the presenting complaint in MG
EYE PAIN • The cornea is innervated by the Ophthalmic Nerve, CN V1. • Possible causes of eye pain • CNS problems affecting CN V1: Meningitis, cavernous sinus thrombosis, aneurysms, migraine • Adjacent structures: sinus problems • Eye problems / inflammations: Conjunctivitis, stye, chalazion • Photophobia: Eye pain upon exposure to light, indicative of • SCOTOMATA: Specific islands or spots of impaired vision; an impaired visual field.
EYELIDS • PTOSIS: Droopy eyelids; failure of lids to open fully. Caused by failure of levator palpebrae, innervated by CN III, or failure of Tarsal Muscle, innervated by sympathetics. Some causes: Horner's Syndrome, Myasthenia Gravis, Encephalitis • LID LAG: Evidence of white sclera between the iris and upper lid margin. This is normally not found. It is a sign of Grave's Disease • STYE: Small abscess caused by infection of sebaceous glands of Zeis. • CHALAZION: Acute inflammation of the meibomian gland
SCLERA • SCLERITIS: Inflammation of the sclera, visible as brown / red infiltrates in sclera on gross examination. Found in autoimmune and collagen vascular diseases, such as SLE, RA. • BLUE SCLERA: Pathognomonic of Osteogenesis Imperfecta. Results from very thin sclera in which the choroid shows through. • BROWN SCLERA: Found in disorder Alkaptonuria (metabolic disorder) • YELLOW SCLERA: Found in Jaundice. It should raise the question of liver disease or hemolytic anemia
EXOPHTHALMOS • Eyes jutting out past eyelids. A sign of Grave's disease, acromegaly, and cavernous sinus thrombosis
CORNEA • KERATOCONJUNCTIVITIS (KERATITIS) SICCA: Found in Sjögren's Syndrome, resulting from autoantibodies against salivary glands resulting in no salivary secretion. • Classic triad of symptoms with Sjögren's Syndrome: • Keratitis Sicca (dry eyes) • Xerostomia (dry mouth) • Rheumatoid Arthritis
INTERSTITIAL KERATITIS: A sign of congenital syphilis. • Hutchinson's Triad: Triad of interstitial keratitis, deafness, and notched teeth is classical evidence for congenital syphilis
ARCUS SENILIS: Gray band of opacity around the cornea. • KAYSER-FLEISCHER RINGS: Copper in Descemet's Membrane. • Circular bands of brownish pigment on lateral and medial margins of cornea. • Found in Wilson's Disease • PINGUECULAE: Small, yellowish elevations of the conjunctivae, which appear brown in Gaucher's disease. It is caused by hyaline degeneration of conjunctival tissue. • ANISOCORIA:Unequal pupils, caused by miosis or mydriasis of one pupil
PUPILS • MARCUS GUNN PUPIL: A pupil that dilates (rather than constricts) as light swings toward it. • It indicates either severe macular disease or optic nerve disease in the affected eye.
PUPILLARY REFLEXES: • Absent Direct Reflex: Indicates a problem with the afferent branch (Trigeminal V1) of the reflex. • Absent Consensual Reflex: Indicates a problem with the efferent branch (CN III, Edinger-Westphal Nucleus) of the affected eye.
CONVERGENCE: Ability of eyes to focus inward and accommodate for near vision. • Impaired convergence is seen with Grave's Disease.
ARGYLL ROBERTSON PUPIL: Indicates a form of CNS Syphilis, Tabes Dorsalis. • Weak or absent direct pupillary reflex. • Normal response to accommodation. • Failure of pupillary dilation with painful stimulation or after atropine administration.
ADIE'S PUPIL: Similar to Argyll Robertson Pupil. • Weak or absent direct pupillary reflex. • Impaired or absent accommodation. • Eye appears larger than the other eye on inspection
MYDRIASIS: Abnormal dilation of pupil, can occur in Diabetes. • MIOSIS: Abnormal constriction of pupil, seen in Horner's syndrome. • HORNER'S SYNDROME: Lost sympathetics from the Superior Cervical Plexus. Ptosis, Miosis, Anhydrosis.
NYSTAGMUS: Nystagmus is normal when looking in the periphery for extended times. All other nystagmus is abnormal. • Causes: Labyrinthitis, MS, Wernicke-Korsakoff, Meniere's Disease
THE EAR • TINNITUS: Ringing in ear. • VERTIGO: • Objective Vertigo: The earth is moving around you. • Subjective Vertigo: You are moving in space.
NOSE and THROAT • EPISTAXIS: Bloody nose. • Transient Epistaxis: May occur with forceful nose-blowing, sneezing, nose-picking, facial trauma. • Recurrent Epistaxis: Differential diagnosis = hypertension, coagulopathies, renal failure, cirrhosis, hereditary hemorrhagic telangiectasia. • RHINOPHYMA: Severe acne rosacea found in association with skin hypertrophy and congestion of subcutaneous tissue, around the nose.
Mouth • Inspect lips: angle of mouth for color and moisture • Teeth: Inspect the number condition of the teeth • Observe the gums for color swelling and tenderness • Inspect the roof of mouth for color architecture of hard palate Proceed with the exam by using a wooden tongue blade and penlight
Parotid gland • Inspect the pre- and infra-auricular region, observing for symmetry. • Palpate the parotid gland
Lacrimal gland • Have the patient close their eyes and observe the upper and outer aspect of the upper lid. • The lid is normally smooth and symmetrical. • Gently retract the upper lid and have the patient gaze to the opposite side. • The lacrimal gland is located under the lid near the outer angle.
Submandibular gland • Observe the submandibular region. • Tilt the patient's head forward and gently roll your fingers over the inner surface of the mandible
THROAT • SOAR THROAT: Infection mononucleosis, strep-throat (streptococcal pharyngitis). • HOARSENESS: Larynigitis, Laryngeal cancer, hypothyroidism, smoking ------> broncho-genic carcinoma
ABNORMAL TASTE: • Hypoguesia: Impaired ability to taste. Seen in URI's, glossitis, stomatitis. • Dysguesia: Unpleasant taste. Differential diagnosis: • Medications: metronidazole, Vitamin and mineral deficiencies: zinc depletion ,Chyronic hypercalcemia, hyperparathyroidism. • Viral hepatitis
TONGUE • MACROGLOSSIA: Large tongue can occur with amyloidosis and acromegaly. • GLOSSITIS: Inflammation on sides, base, and underside of tongue. • Vitamin and mineral deficincies • Medications: metronidazole, phenytoin • Infections: candidiasis • Pernicious Anemia • Cytotoxic drugs, radiotherapy
Thyroid Gland • Inspect the neck for fullness over the thyroid region. • While standing behind the patient, affix the trachea on one side, gently tilt the head and roll the thyroid gland over the tracheal rings. • Repeat this procedure on the opposite side. • Ask the patient to swallow water, extend the neck gently and observe the mobility of the thyroid gland while swallowing.
Palpate the thyroid gland while swallowing, separately examining each lateral lobe and the isthmus • Some prefer to examine the thyroid from the front. • Evaluate Thyroid gland for consistency, tenderness, size and approximate weight
The Thyroid gland is palpable and rises along with thyroid and cricoid cartilage during swallowing, in persons with a slender neck. • It is soft and approximately weighs no more than 20 grams. • It is often not palpable with aging
GOITER • Goiter refers to any enlargement of the thyroid gland. Because of the gland's location at the front of the neck, this condition becomes visually apparent • Diffuse goiter refers to a uniformly enlarged thyroid. It is associated with disease processes (for example, Hashimoto's and Grave' diseases) and is endemic to areas in the world where the diet is iodine deficient. In such areas, goiter can become quite large, appearing as a huge, bizarre growth hanging down from below the chin. Diffuse goiter is a consequence of stimulation of the thyroid to hypertrophy and hyperplasia
The cause of lumpy or nodular goiter is not well understood. Nodules raise concerns about thyroid cancer (see below), and those that are hot or autonomously functioning are of concern because they may eventually cause hyperthyroidism
HYPOTHYROIDISM (Myxedema • Hypothyroidism refers to clinical status when thyroid hormone concentrations are below the euthyroid (eu- meaning normal) range. Symptoms may include goiter (enlarged thyroid), fatigue cold intolerance, weight gain, constipation, dry skin, puffy face, depression, and loss of hair. Severe manifestations may include hypothermia, seizures, stupor, and coma.
Primary Hypothyroidism • In primary hypothyroidism, the disorder is at the site of the thyroid gland itself. Primary hypothyroidism may be acquired or congenital • The most common cause of acquired hypothyroidism is Hashimoto's thyroiditis. • Other causes of acquired hypothyroidism include thyroid ablation, antithyroid drugs administration, and iodine deficiency