Subject: Physical Diagnosis Topic: Head and Neck 2 Lecturer: Dr.

Acuin Date of Lecture: July 25, 2011 Transcriptionist: Pinay Pages: 11

Lecture Objectives 1. Review physical exam maneuvers 2. Correlate signs and symptoms with

It is important that signs and symptoms be correlated with: 1. Change in anatomy 2. Change in function 3. Pathologic process a. Local

anatomy and pathophysiology 3. Recognize normal from abnormal findings

Principles of diagnosis y Clinical history careful, detailed, complete

b. Distant ***Means that prior knowledge has to be correlated with the signs and symptoms that the patient presents to you so you will not go all over the place asking irrelevant questions on the patient.

description of symptoms y Physical examination the disease. o Things that you can see trough inspection, palpate, hear through auscultation, or trough percussion Remember: IPPA ***Clinical History taking and Physical Examination are the cornerstone of physical diagnosis. 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 patient s 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 less points you, the diagnosis. Example Case: Patient presents with changes in voice before developing respiratory difficulty or shortness of breath we can assume that location of lesion is on vocal folds -If voice changes occurs first before difficulty of breathing lesion is somewhere in the vocal folds or in the glottis -If difficulty of breathing occurs first before voice change lesion is somewhere below the vocal folds, or in the trachea, epiglottis, pharynx that will later involve the vocal folds secondarily, causing the voice change. for objective evidence of

Challenges in Diagnosis 1. Multiple symptoms / signs one disease

Temporomandibular joint dysfunction 1. Teeth grinding and teeth clenching (bruxism) 2. Habitual gum chewing or fingernail biting 3. Dental problems and malocclusion 4. Trauma to the jaws 5. Stress 6. Occupational tasks 7. Headache and facial pain 8. Ear pain and ear fullness 9. Tinnitus and other sounds 10. Dizziness Example Case: A patient come to you for ear pain and dizziness you inspect the ears and find that its normal, only to find out that the problem really is the temporomandibular joint. Is that the reason why the patient has ear pain and experiences dizziness? Yes. TMJ syndrome can cause stress, sleeplessness, and many psychological reactions from constant pain in

SY 2011-2012

the TMJ, which can lead to dizziness. Ear pain is a referred pain from TMJ dysfunction. 2. Multiple diseases one symptom / sign Ear pain y Auricle - trauma, hematoma, burn, perichondritis, gout, eczema, impetigo, carcinoma, herpes zoster y Canal external otitis, carbuncle, cerumen,

o o

High specificity Done in selected diagnoses

3. Build your memory bank A Philosophical Framework: Clinical diagnosis is a performance art, judged for its accuracy and efficiency. To perform well, you need a memory bank of moves and associations.

foreign body, carcinoma, insect invasion, herpes zoster y Middle ear acute otitis media, acute 4. Beware of jumping to conclusions

Some judgment heuristics y y Representativeness The probability that sign / symptom is due to a specific disease y y Availability The probability of a disease based on the most recently recalled experience y y Anchoring The probability of a disease based on the average experience

mastoiditis, carcinoma y Referred pain carious laryngitis, teeth, unerupted lower third molar, TMJ dysfunction, tonsillitis, trigeminal

cervical

lymphadenitis,

neuralgia, laryngeal cancer Example Case: 1. A lady with carcinoma on the lateral side of tongue, complaining of ear pain: - Referred pain o no problem in the ears o trigeminal nerve: supplies the anterior 2/3 of the tongue, also supply part of the ear. 2. Patient with carcinoma of larynx complaining of ear pain: - Referred pain o caused by glossopharyngeal and vagal nerve that supply the larynx, also supply the middle ear. Solutions: 1. Build a full story In history taking note: y y y y y Sequence / progression Severity / prominence Relieving / provoking agents Medical risk factors Personal risk factors

Basic P. E. Techniques (Remember: IPPA) A. Inspection - most areas are accessible to direct visualization - w/ good illumination. B. Palpation - manual examination of the neck, face, oral & buccal areas C. Percussion - to elicit tenderness of bone D. Auscultation - in vascular lesions & toxic goiter Head -Size y y

The patient is normocephalic (normal size of head) The anteroposterior diameter (21 22 cm), width (17 18 cm), and circumference (54 57 cm) are within normal limits Normality refers to the range of values within which 99% of people of the patient s sex, age and race would fall

2. Organize your moves y Level 1 screening maneuver (I cough

after I m exposed to dust) o o y High sensitivity Done in every patient

-Shape y The patient s head is round and symmetrical y There are no gross deformities or masses -Consistency -Proportion y 1/7 of height Face -Size

Level 2 probing maneuver (after a symptom or a screening sign (Do you have pets?)

y y y

The size of the patient s face is proportional to the rest of her body The anteroposterior, superoinferior, and right to left diameters are WNL. Normality refers to the range of values within which 99% of people of the patient s sex, age, and race would fall

Middle

ear

eardrum

perforation,

Eustachian tube dysfunction, otitis media, otosclerosis y Inner ear fevers, Meniere s disease, syphilis, temporal bone

labyrinthitis,

-Shape y The patient s head is oval/round and asymmetrical y There are no gross deformities or masses y Proportions: o Eyes should be midway from top to bottom o Hair line to midbrow : midbrow to tip of nose : tip of nose to chin 1:1:1 o Edge of lips should hit medial aspect of cornea o Ala que nasi should hit of medial canthus o Intercanthal distance: normal = 30 mm o Telecanthus distance: normal = 45 mm o Interpupillary: normal = 60 mmd Neck -Size y The size of the patient s neck is proportional to the rest of her body y The neck circumference with WNL (35 40 cm) y Normality refers to the range of values within which 99% of people of the patient s sex, age, and race would fall -Shape y The patient s neck is asymmetrical y There are no gross deformities or masses ***Sternocleidomastoid is the huge landmark in the neck. MAJOR SYMPTOMS OF EAR DISEASES y y y y y y HEARING LOSS VERTIGO - spinning sensation TINNITUS - ringing or buzzing noises EAR DISCHARGE - otorrhea EAR PAIN - otalgia EAR ITCHINESS = may present in various combinations

fracture, acoustic nerve tumor, acoustic trauma y Drugs aminoglycosides Dizziness Causes: y Endocrine hypothyroidism, quinine, salicylates,

hypoparathyroidism, aldosteronoma y y Inflammatory vestibular neuronitis Infectious syphilis y Metabolic pellagra, alcoholism, pernicious anemia, fluid and electrolyte imbalance, cerebral hypoxia y y y y Mechanical fractures, leaks, Eyes glaucoma, refractive errors Neoplastic brain tumors Neurologic neuropathy, MS y Vascular hypotension y Psychosocial anxiety disorder Vertigo Causes: y Labyrinthine perilymph fistula, serous viral labyrinthitis, labyrinthitis, panic attack, generalized hypotension, orthostatic migraine, seizures, meningitis, brain abscess,

labyrinthine fistula, otitis media, Meniere s disease, BPPV

Ear symptom Tinnitus Causes: y Outer ear cerumen, foreign body, polyp

y y

CN VIII tumor, infections, trauma Brainstem nuclei infections, PICA

syndrome, Wallenberg syndrome y Central insufficiency, migraine, brainstem vertebrobasilar hemorrhage,

cerebellopontine angle tumors, intraaxial

tumors, abscess.

multiple

sclerosis,

intracranial

Otoscopy

7 habits of successful ear examiners: 1. Begin with external inspection 2. Clean the canal first 3. Look for the cone of light 4. Look for the limits of the drum 5. Use the largest fitting ear speculum 6. Keep still when inside the canal 7. Some eardrums are visible without an otoscope. Ear examination External auditory canals -Size y The size of the canals are WNL (around 1 cm diameter in adults) -Shape y The canals are slightly inclined superiorly and posteriorly form lateral to medial ends y The canals are patent and symmetrical, without cerumen, masses scars, lesions or discharge Tympanic Membranes -Size y The tympanic membranes are WNL (1 cm) -Shape y The TMs are round and slightly inclined laterally -Integrity y The pars flaccid and pars tensa are intact, pinkish grey, and translucent, without scars, masses, or discharge -Landmarks y The processes of the malleus, incus, and stapes

Pinnae -Size y The size of the patient s ears are proportional to the rest of the head -Shape y The patient s pinnae are symmetrical, without medial adhesions or lateral displacements y There are no gross deformities Otoscopic examination

Types of Eardrum Perforation: 1. Central y partial or total

2. Marginal y 3. Attic y located superiorly Involves the tympanic ring

Inspection

of

the

external

ear

canal

and

visualization of the tympanic membrane 4

Painless dysphagia: Oropharyngeal y y y y Cleft palate Cervical osteoporosis Xerostomia (dry mouth) Globus hystericus (sensation of having a lump in the throat) y y y ORO-PHARYNGEAL DISEASE may present as: y y y y y y y y y y Pain Ulceration y Bleeding Mass Halitosis - (bad breath) Nasal obstruction Odynophagia (pain on swallowing) Dysphagia (difficulty in swallowing) Deafness Snoring Esophageal y y y y y y y y y y y y y Foreign body Carcinoma Esophagitis Diverticulum Hiatal hernia Stricture Scleroderma Dermatomyositis Sjogren s syndrome Amyloidosis Thyrotoxicosis Aortic aneurysm Vertebral spurs y y y Myasthenia gravis Bulbar paralysis Hepatolenticular disease) Parkinson s disease Stroke Botulism Poisoning (lead, alcohol, fluoride) degeneration (Wilson s

Odynophagia y y Glossitis- inflammation of the tongue Stomatitis- inflammation of the mucous lining of mouth, cheeks, gums, tongue, lips y y y y y y y y Tonsillitis Pharyngitis Laryngitis Lingual ulcer Carcinoma Pemphigus Acid/base ingestion Plummer-Vinson dysphagia y y y y y y y Angioneurotic edema Cervical adenoiditis Carotid arteritis Infected neck cysts or sinuses Carotid body tumor Rabies Tetanus Syndrometriad of

Lip deformities y y Cleft lip Lip enlargement Acromegaly cretinism, myxedema,

Patient with cretinism 5

y y

Vesicles herpes simplex Cheilosis (angular stomatitis) deficiency, ill-fitting dentures riboflavin

Patient with Hutchinson s teeth y Patient with cheilosis- inflammation and cracking of the corners of the mouth y y y Cellulitis or carbuncles Squamous / basal cell carcinoma Rhagades / chancre y y Alveolar abscess Periodontitis (pyorrhea alveolaris) Bleeding gums pyorrhea, stomatitis,

toothbrushing, caries, tartar, scurvy, metal poisoning, epulis, papilloma, pemphigus, leukemia, hemophilia y y Gingival hyperplasia Epulis and granuloma lymphoma, aplastic anemia,

Patient with rhagades

Patient with epulis- benign lesion of gingiva Odor of breath y Patient with chancre Teeth and gum deformities y y Tooth absence or loss, worn out, Carious teeth, devitalized teeth y y y y Fetor oris atrophic tonsillar or dental infections, rhinitis, pyloric obstruction,

bronchiectasis, lung abscess Acetone diabetic or starvation acidosis Ammonia uremia Musty liver disease Alcohol

Pharyngeal pain, acute y y y Patient with carious y y Hutchinson s teeth (congenital syphilis) notched from syphilis y Bacterial tonsillopharyngitis Diphtheria - pseudomembrane Vincent s angina (necrotizing ulcerative stomatitis) pseudomembrane Viral tonsillopharyngitis Infectious mononucleosis

Use of tongue blade to depress one side of tongue

Stiff neck y Congenital torticollis

Patient with torticollis- lateral flexion of neck y Idiopathic syndrome y Inflammatory osteomyelitis, fibromyalgia, myofascial pain

retropharyngeal abscess, TB, rheumatoid arthritis, ankylosing spondylitis Palpation of tonsillar fosa and base of tongue y Infectious pharyngitis, laryngitis, meningitis, tetanus y Metabolic/toxic hypercalcemia y Mechanical torticollis y Neoplastic metastatic carcinoma y Psychosocial malingering thyroid cancer, lymphoma, carcinoma, oropharyngeal neck trauma, acquired strychnine,

Landmarks of the Neck

SYMPTOMS OF NECK DISEASE Check : y y y y y y NECK MASS OR SWELLING LOCATION W/ OR W/O PAIN DURATION ANY CHANGE IN SIZE ASSOCIATED SX: hoarseness, swallowing difficulty, dyspnea y NECK STIFFNESS

Palpation of the Thyroid Gland

y y y y y y y y y y

Foreign body Sicca Vocal fold swelling Vocal fold surface lesions Neoplasms Ulcers Weakness Laryngeal cartilage Laryngeal compression Irradiated neck

SYMPTOMS OF NOSE DISEASES y y y y y Nasal obstruction Nasal discharge Epistaxis (nasal bleeding) Sneezing Nasal itchiness

External nasal deformities y y Major Symptoms of Laryngeal Diseases y HOARSENESS OR DYSPHONIA (disorders of voice) disease o y y y y y COUGH HEMOPTYSIS PAIN ON PHONATION DYSPNEA DYSPHAGIA Patient with Saddle nose Hoarseness Acute y y y y y y y Overuse Infections Drugs Angioedema Foreign body aspiration Laryngeal spasm Burns Chronic y Occupational overuse Patient with Rhinophyma y y Skewed nose fracture Rhinophyma adenomas of the skin multiple sebaceous very specific symptom of laryngeal y y Congenital Cleft nose Acquired Saddle nose o Infection syphilis Trauma septal abscess congenital or acquired

Internal nasal deformities y y y y y Folliculitis small superficial abscess Furunculosis Septal deviation Septal perforation Septal abscess

Epistaxis Localized causes y y Forceful expiration -Coughing, sneezing Trauma -Nose picking, fractures,

lacerations, foreign body y Ulceration -Adenoid hypertrophy, cancer, nasopharyngeal angiofibroma

Bilateral rhinorrhea (runny nose) y y y y Allergic rhinitis Non-allergic rhinitis Drug-induced rhinitis Atrophic rhinitis y y y y y Varicosities

Multiple

hereditary

telangiectasia, portal cirrhosis Acute infection - Rhinitis, sinusitis

Generalized causes Physiologic - Exertion Arterial hypertension 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-

Unilateral rhinitis y y y y Choanal atresia Foreign body Neoplasm Cerebrospinal fluid rhinorrhea

Facial pain and swelling y y y y y y y y Facial pain Acute bacterial rhinosinusitis Purulent nasal discharge Acute and chronic bacterial rhinosinusitis Periorbital edema Periorbital abscess Ocular palsies Cavernous sinus thrombosis

Mountain climbing, flying

Anterior rhinoscopy

Intranasal masses y y y y y y y Polyps Mucocele and pyocele Neoplasm Papilloma Osteoma / chondroma Squamous cell carcinoma Midline granuloma

Nasal trauma y y Septal hematoma Fracture

Transillumination of frontal sinus

Bimanual palpation of submaxillary gland

Palpation of parotid gland Transillumination of maxillary Sinus

Palpation of Frontal and Maxillary sinuses for Retraction of cheek to show opening of Stensen s duct tenderness

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Trismus- inability to open the mouth

------------------End of Transcription ------------Let your hearts not be troubled. Believe in God, believe also in Me. In my Father s house are many rooms. If it were not so, would I have told you that I go to prepare a place for you. I will come again and will take you to myself, that where I am you may be also. John 14:1-3

Localized y y y y y Impacted third molar TMJ dysfunction Trigeminal neuralgia Scleroderma Dermatomyositis of face

Systemic y y y y y y y y y y y y y y Trichinosis Rabies Tetany Tetanus Strychnine poisoning Typhoid fever Cholera Sepsis Encephalitis Seizure Catalepsy Catatonia Hysteria Malingering

Palpation of TMJ

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