Head and Neck2- PD

8/6/2019 Head and Neck2- PD

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Lecture Objectives

1. Review physicalexammaneuvers2. Correlate signs and symptoms withanatomy and pathophysiology

3. Recognizenormal fromabnormal findings

P

rinciples of diagnosisy Clinical history careful, detailed, completedescription of symptoms

yPhysical examination forobjectiveevidenceofthedisease.

oThings that youcan seetrough inspection,palpate, hear through auscultation, or

trough percussion

Remember: IPPA

***Clinical History takingand Physical Examination

arethe cornerstone of physicaldiagnosis. It is an

act of interacting and forming a relationship with

the patient.

***The outcome of history taking is a careful,

detailed and sequential description of what the

patients symptoms have been over a period of

time.

***The description has to be sequential because

any disease can present with many symptoms.

Particular progression tells you, or more or lesspoints you,thediagnosis.

Example

Case:

Patient presents with changes in voice before

developing respiratory difficulty or shortness of

breath wecanassumethatlocation oflesionis on

vocal folds

-If voice changes occurs first before

difficulty ofbreathing lesionis somewhere inthevocal folds orintheglottis

-Ifdifficulty ofbreathing occurs firstbefore

voicechangelesionis somewherebelowthevocal

folds, orinthetrachea,epiglottis, pharynxthatwill

laterinvolvethevocal folds secondarily,causingthe

voicechange.

It is important that signs and symptoms be

correlatedwith:

1. Changeinanatomy

2. Changeinfunction

3. Pathologic process

a. Local

b. Distant

***Means that prior knowledge has to be

correlated with the signs and symptoms that the

patient presents to you so youwillnotgo all over

the placeaskingirrelevantquestions onthe patient.

Challenges in Diagnosis

1. Multiple symptoms / signs one disease

Temporomandibularjointdysfunction

1. Teeth grindingandteeth clenching (bruxism)

2. Habitualgumchewing or fingernailbiting

3. Dental problems andmalocclusion

4. Traumato thejaws

5. Stress

6. Occupationaltasks

7. Headacheand facial pain

8. Ear painandear fullness

9. Tinnitus and other sounds

10. Dizziness

Example

Case:

A patientcometo you forear painanddizziness

youinspecttheears and findthatits normal, only to

find out that the problem really is the

temporomandibularjoint.

Is thatthereasonwhy the patient has ear painand

experiences dizziness? Yes.

TMJ syndromecancause stress, sleeplessness,and

many psychologicalreactions fromconstant pain in

Subject: Physical DiagnosisTopic: Head and Neck 2Lecturer: Dr. AcuinDate of Lecture: July 25, 2011Transcriptionist: Pinay Pages: 11 S

Y

2011-2012


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theTMJ,which can lead to dizziness. Ear pain is a

referred pain fromTMJdysfunction.

2. Multiple diseases one symptom / signEar pain

yAuricle - trauma, hematoma,burn, perichondritis,gout,eczema,impetigo,carcinoma, herpes zoster

yCanal external otitis, carbuncle, cerumen,foreign body, carcinoma, insect invasion, herpes

zoster

y Middle ear acute otitis media, acutemastoiditis,carcinoma

yReferred pain unerupted lower third molar,carious teeth, TMJ dysfunction, tonsillitis,

laryngitis, cervical lymphadenitis, trigeminal

neuralgia,laryngealcancer

Example

Case:

1. A lady with carcinoma on the lateral side of

tongue,complaining ofear pain:

- Referred pain

o no problemintheearso trigeminal nerve: supplies theanterior 2/3 of the tongue, also

supply part oftheear.

2. Patientwith carcinoma oflarynxcomplaining of

ear pain:

- Referred pain

o caused by glossopharyngeal andvagalnerve that supply the larynx,

also supply themiddleear.

Solutions:

1. Build a full storyIn history takingnote:

y Sequence / progressiony Severity / prominencey Relieving / provokingagentsy Medicalrisk factorsy Personalrisk factors

2. Organize your movesy Level 1 screening maneuver (I coughafter Imexposedto dust)

o High sensitivityo Doneinevery patient

y Level 2 probing maneuver (after asymptom ora screening sign(Do you have

pets?)

o High specificityo Donein selecteddiagnoses

3. Build your memory bankA Philosophical Framework:

Clinicaldiagnosis is a performanceart,judged forits

accuracy andefficiency. To performwell, youneed

a memory bank ofmoves andassociations.

4. Beware of jumping to conclusionsSomejudgment heuristics

y Representativenessy The probability that sign / symptom is dueto a specificdisease

y Availabilityy The probability of a disease based on themostrecently recalledexperience

y Anchoringy The probability of a disease based on the

averageexperience

Basic P. E. Techniques (Remember:IPPA)

A. Inspection - mostareas areaccessible to direct

visualization -w/ goodillumination.

B. Palpation - manual examination of the neck,

face, oral & buccalareas

C.Percussion - to elicittenderness ofbone

D.Auscultation - invascularlesions & toxicgoiter

Head

-Size

y The patient is normocephalic (normal sizeof head)

y Theanteroposteriordiameter (21 22 cm),width (17 18 cm),andcircumference (54

57 cm)arewithinnormallimits

y Normality refers to the range of valueswithinwhich 99% of people ofthe patients

sex,ageandracewould fall

-Shape

y The patients head is round andsymmetrical

y Thereareno gross deformities ormasses-Consistency

-Proportion

y 1/7 of heightFace

-Size


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y The size ofthe patients faceis proportionalto therest of herbody

y The anteroposterior, superoinferior, andrightto leftdiameters areWNL.


sex,age,andracewould fall

-Shape

y The patients head is oval/round andasymmetrical

y Thereareno gross deformities ormassesy Proportions:

o Eyes should be midway from top tobottom

o Hairlinetomidbrow:midbrowto tip ofnose:tip ofnoseto chin1:1:1

o Edge oflips should hitmedialaspect ofcornea

o Ala que nasi should hit of medialcanthus

o Intercanthaldistance: normal = 30mmo Telecanthus distance: normal = 45mmo Interpupillary: normal = 60mmd

Neck

-Size

y The size of the patients neck isproportionalto therest of herbody

y Theneckcircumferencewith WNL (35 40cm)


sex,age,andracewould fall

-Shape

y The patients neckis asymmetricaly Thereareno gross deformities ormasses***Sternocleidomastoidis the hugelandmarkinthe

neck.

MAJORSYMPTOMS OF EAR DISEASES

y HEARING LOSSy VERTIGO - spinning sensationy TINNITUS - ringing orbuzzingnoisesy EAR DISCHARGE - otorrheay EAR PAIN - otalgiay EAR ITCHINESS = may present in variouscombinations

Ear symptom

Tinnitus

Causes:

y Outer earcerumen, foreignbody, polyp

y Middle ear eardrum perforation,Eustachian tube dysfunction, otitis media,

otosclerosis

y Inner ear Menieres disease, syphilis,fevers, labyrinthitis, temporal bone

fracture, acoustic nerve tumor, acoustic

trauma

y Drugs quinine, salicylates,aminoglycosides

Dizziness

Causes:

y Endocrine hypothyroidism,hypoparathyroidism,aldosteronoma

y Inflammatoryvestibularneuronitisy Infectious meningitis, brain abscess,

syphilis

y Metabolic pellagra,alcoholism, perniciousanemia, fluid and electrolyte imbalance,

cerebral hypoxia

y Mechanical fractures,leaks,y Eyes glaucoma,refractiveerrorsy Neoplasticbraintumorsy Neurologic migraine, seizures,neuropathy,MS

y Vascular hypotension, orthostatichypotension

y Psychosocial panic attack, generalizedanxiety disorder

Vertigo

Causes:

y Labyrinthine serous labyrinthitis,perilymph fistula, viral labyrinthitis,

labyrinthine fistula, otitis media,Menieres

disease, BPPV

y CNVIIItumor,infections,traumay Brainstem nuclei infections, PICA

syndrome,Wallenberg syndrome

y Central migraine, vertebrobasilarinsufficiency, brainstem hemorrhage,

cerebellopontine angle tumors, intraaxial


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tumors, multiple sclerosis, intracranial

abscess.

7 habits of successful ear examiners:

1. Beginwith externalinspection

2. Cleanthecanal first

3. Look forthecone oflight

4. Look forthelimits ofthedrum

5. Usethelargest fittingear speculum

6. Keep stillwheninsidethecanal

7. Someeardrums arevisiblewithoutan otoscope.

Ear examination

Pinnae

-Size

y The size of the patients ears areproportionalto therest ofthe head

-Shape

y The patients pinnae are symmetrical,without medial adhesions or lateral

displacementsy Thereareno gross deformities

Otoscopic examination

Inspection of the external ear canal and

visualization of the tympanic membrane

Otoscopy

External auditory canals

-Size

y The size of the canals are WNL (around 1cmdiameterinadults)

-Shape

y The canals are slightly inclined superiorlyand posteriorly formlateraltomedialends

y The canals are patent and symmetrical,without cerumen,masses scars, lesions or

discharge

TympanicMembranes

-Size

y Thetympanicmembranes areWNL (1 cm)-Shape

y The TMs are round and slightly inclinedlaterally

-Integrity

y The pars flaccid and pars tensa are intact,pinkish grey,andtranslucent,without scars,

masses, ordischarge

-Landmarks

y The processes of the malleus, incus, andstapes

Types of Eardrum Perforation:

1. Centraly partial ortotal

2. Marginaly Involves thetympanicring

3. Atticy located superiorly


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ORO-PHARYNGEAL DISEASEmay presentas:

y Painy Ulcerationy Bleedingy Massy Halitosis - (badbreath)y Nasal obstructiony Odynophagia (pain on swallowing)y Dysphagia (difficulty in swallowing)y Deafnessy Snoring

Odynophagia

y Glossitis- inflammation ofthetonguey Stomatitis- inflammation of the mucouslining ofmouth,cheeks,gums,tongue,lips

y Tonsillitisy Pharyngitisy Laryngitisy Lingualulcery Carcinomay Pemphigusy Acid/baseingestiony Plummer-Vinson Syndrome- triad ofdysphagia

y Angioneuroticedemay Cervicaladenoiditisy Carotidarteritisy Infectedneckcysts or sinusesy Carotidbody tumory Rabiesy Tetanus

Painless dysphagia:

Oropharyngeal

y Cleft palatey Cervical osteoporosisy Xerostomia (drymouth)y Globus hystericus (sensation of having alump inthethroat)

y Myastheniagravisy Bulbar paralysisy Hepatolenticular degeneration (Wilsonsdisease)

y Parkinsons diseasey Strokey Botulismy Poisoning (lead,alcohol, fluoride)

Esophageal

y Foreignbodyy Carcinomay Esophagitisy

Diverticulum

y Hiatal herniay Stricturey Sclerodermay Dermatomyositisy Sjogrens syndromey Amyloidosisy Thyrotoxicosisy Aorticaneurysmy Vertebral spurs

Lip deformities

y Cleftlipy Lip enlargement cretinism, myxedema,

Acromegaly

Patient with cretinism


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y Vesicles herpes simplexy Cheilosis (angular stomatitis) riboflavindeficiency,ill-fittingdentures

Patient with cheilosis- inflammation and cracking of

the corners of the mouth

y Cellulitis orcarbunclesy Squamous / basalcellcarcinomayRhagades / chancre

Patient with rhagades

Patient with chancre

Teeth and gum deformities

y Tooth absence orloss,worn out,y Carious teeth,devitalizedteeth

Patient with carious

y Hutchinsons teeth notched from syphilis(congenital syphilis)

Patient with Hutchinsons teeth

y Alveolarabscessy Periodontitis (pyorrheaalveolaris)y Bleeding gums pyorrhea, stomatitis,toothbrushing, caries, tartar, scurvy,metal

poisoning, epulis, papilloma, pemphigus,

leukemia, lymphoma, aplastic anemia,hemophilia

y Gingival hyperplasiay Epulis andgranuloma

Patient with epulis- benign lesion of gingiva

Odor of breath

y Fetor oris tonsillar or dental infections,atrophic rhinitis, pyloric obstruction,

bronchiectasis,lungabscess

y Acetonediabetic or starvationacidosisy Ammoniauremiay Musty liverdiseasey Alcohol

Pharyngeal pain, acute

y Bacterialtonsillopharyngitisy Diphtheria - pseudomembraney Vincents angina (necrotizing ulcerative

stomatitis) pseudomembrane

y Viraltonsillopharyngitisy Infectiousmononucleosis


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Use of tongue blade to depress one side of tongue

Palpation of tonsillar fosa and base of tongue

SYMPTOMS OFNECKDISEASE

Check:

y NECKMASS OR SWELLINGy LOCATIONy W/ ORW/O PAINy DURATIONy ANY CHANGE IN SIZEy ASSOCIATED SX: hoarseness, swallowingdifficulty,dyspnea

y NECK STIFFNESS

Stiff neck

y Congenitaltorticollis

Patient with torticollis- lateral flexion of neck

y Idiopathic fibromyalgia, myofascial painsyndrome

y Inflammatory osteomyelitis,retropharyngeal abscess, TB, rheumatoid

arthritis,ankylosing spondylitis

y Infectious pharyngitis, laryngitis,meningitis,tetanus

y Metabolic/toxic strychnine,hypercalcemia

y Mechanical neck trauma, acquiredtorticollis

y Neoplastic thyroid cancer, lymphoma,metastatic carcinoma, oropharyngeal

carcinoma

y PsychosocialmalingeringLandmarks of the Neck


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Palpation of the Thyroid Gland

Major Symptoms of Laryngeal Diseases

y HOARSENESS OR DYSPHONIA (disorders ofvoice)very specific symptom oflaryngeal

disease

y COUGHy HEMOPTYSISy PAIN ON PHONATIONy DYSPNEAy DYSPHAGIA

Hoarseness

Acute

y Overusey Infectionsy Drugsy Angioedemay Foreignbody aspirationy Laryngeal spasmy Burns

Chronic

y Occupational overuse

y Foreignbodyy Siccay Vocal fold swellingy Vocal fold surfacelesionsy Neoplasmsy Ulcersy Weaknessy Laryngealcartilagey Laryngealcompressiony Irradiatedneck

SYMPTOMS OFNOSE DISEASES

y Nasal obstructiony Nasaldischarge

y Epistaxis (nasalbleeding)y Sneezingy Nasalitchiness

External nasal deformities

y Congenitaly Cleftnosey Acquiredy Saddlenose

o Infection congenital or acquiredsyphilis

o Trauma septalabscess

Patient with Saddle nose

y Skewednose fracturey Rhinophyma multiple sebaceousadenomas ofthe skin

Patient with Rhinophyma


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Internal nasal deformities

y Folliculitis small superficialabscessy Furunculosisy Septaldeviationy Septal perforationy Septalabscess

Bilateral rhinorrhea (runny nose)

y Allergicrhinitisy Non-allergicrhinitisy Drug-inducedrhinitisy Atrophicrhinitis

Unilateral rhinitis

y Choanalatresiay Foreignbodyy Neoplasmy Cerebrospinal fluidrhinorrhea

Facial pain and swelling

y Facial painy Acutebacterialrhinosinusitisy Purulentnasaldischargey Acuteandchronicbacterialrhinosinusitisy Periorbitaledemay Periorbitalabscessy Ocular palsiesy Cavernous sinus thrombosis

Intranasal masses

y Polypsy Mucoceleand pyoceley Neoplasmy Papillomay Osteoma / chondromay Squamous cellcarcinomay Midlinegranuloma

Nasal trauma

y Septal hematomay Fracture

Epistaxis

Localizedcauses

y Forceful expiration -Coughing, sneezingy Trauma -Nose picking, fractures,lacerations, foreignbody

y Ulceration -Adenoid hypertrophy, cancer,nasopharyngealangiofibroma

y Varicosities - Multiple hereditarytelangiectasia, portalcirrhosis

y Acute infection - Rhinitis, sinusitisGeneralizedcauses

y Physiologic - Exertiony Arterial hypertensiony Venous hypertension - SVC obstruction,

pulmonary emphysema

y Blood coagulation disorders - Leukemia,hemophilia

y Infection - Typhoid, dengue, influenza,pertussis,rheumatic fever

y Changes in atmospheric pressure-Mountainclimbing, flying

Anterior rhinoscopy


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Transillumination of frontal sinus

Transillumination of maxillary Sinus

Retraction of cheek to show opening of Stensens

duct

Bimanual palpation of submaxillary gland

Palpation of parotid gland

Palpation of Frontal and Maxillary sinuses for

tenderness


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Trismus- inability to openthemouth

Localized

y Impactedthirdmolary TMJdysfunctiony Trigeminalneuralgiay Sclerodermay Dermatomyositis of face

Systemic

y Trichinosisy Rabiesy Tetanyy Tetanusy Strychnine poisoningy Typhoid fevery Choleray Sepsisy Encephalitisy Seizurey Catalepsyy Catatoniay Hysteriay Malingering

Palpation of TMJ

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Let your hearts not be troubled. Believe in God,

believealso inMe. Inmy Fathers housearemany

rooms. Ifitwerenot so,would I havetold youthat I

go to preparea place for you. I willcomeagainand

willtake youtomyself,thatwhere I am youmay be

also.

John 14:1-3

Head and Neck2- PD

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