Physical Signs Of The Head And Neck

Physical signs Symptom- what the patient feels Physical sign- what the doctor finds at clinical

examination of the patient’s segments. Symptom is subjective Physical sign is objective Clinical diagnosis = symptoms + signs Final diagnosis= symptoms + signs +

lab.tests + investigations.

SURFACE LANDMARKS OF THE HEAD Nasion External occipital protuberance Vertex Superior nuchal line Mastoid process of the temporal bone Zygomatic arch Superficial temporal artery Facial artery Parotid duct

Surface landmarks

Sebaceous cysts Swelling-cystic mass-cystic tumor-lump Hairy parts of the body- scalp The mouth of the seb. gland opens into the

hair follicle If blocked mouth, seb. gland becomes distended

Seb. Cyst History- slow growing Symptoms-a lump that gets scratched when

the patient is combing the hair Such scratches may get infected If the cyst becomes infected it enlarges rapidly and becomes acutely painful

Seb. Cyst- examination-physical signs Position-hairy parts of the body Color- the skin overlying the cyst normal unless it

is infected Tenderness- not tender unless infected Temperature-normal except when infected Shape- spherical Size- variable: mm-4-5 cm. Surface- smooth Edge-well defined Composition- hard depending on the pressure in the cust “cheesy material”

Sebaceous cyst of the scalp

Sebaceous cyst

Surgical treatment- excision

Intact sebaceous cystspecimen

Cut section- seb.cyst- “cheesy material”-sebum

Lipoma-case report A 59-year-old woman was admitted with a

10 years' history of a painless swelling at the right thigh. The lesion became ulcerative over the past few months with mild pain. She had no significant medical and surgical history. Examination revealed normal vital signs, chest, heart, abdominal and rectal examinations.

Lipoma On local examination, a large mass

occupying the posterior aspect of the lower two thirds of the right thigh was confirmed. There was an ulcerative lesion at the posteromedial aspect of the mass. The right popliteal artery was difficult to palpate, but the posterior tibial and dorsalis pedis were normal. There was no neuronal abnormality.

Lipoma- case report Blood tests showed normal blood count,

liver function, urea and electrolytes as well as ESR. She had a normal chest and abdominal X-ray. The X-ray of the right thigh showed a soft tissue shadow and normal bone. Surgical excision was performed and the findings were consistent with a giant lipoma. The wound was closed easily as there was redundant skin because of the size of the

Lipoma- case report The patient had an uneventful recovery

and was discharged home with a very good condition. Histology of the specimen reported benign

lipoma.

Huge lipoma of the thigh

Ulcerated lipoma on the post-medial thigh

Specimen- 3.2 Kg.

Lipoma This is the external

surface of a lipoma, a benign tumor of adipocyte origin. •The bright yellow color is typical of fat. •Note the lobulated appearance. This is also typical of this lesion. •This particular tumor arose in the subcutaneous fat (note

Case Report-lipoma

A 60 year old male presented in out patient

clinic with history of progressively increasing swelling in right thigh, which he noticed 3½ years back. Swelling was otherwise asymptomatic except that he had to wear loose fitting trousers. On examination, right thigh girth was grossly increased as compared to the left thigh.

Lipoma There were erythema ab agni over the medial

aspect of both thighs (as is usual in Kashmiri people because of Kangri – “the fire pot”). The swelling was firm, non-tender and free

from underlying structures.

Lipoma

CT scan of the right thigh was done which revealed a hypodense mass in the posterior compartment of the thigh beneath the hamstring muscles



Lipoma- case report  FNAC of the swelling revealed mature fat cells, suggestive

of lipoma.  The patient was operated on under general anaesthesia, in

prone position and the tumour was found beneath the hamstring muscles and was dissected out easily because of the pseudocapsule.  Wound was closed in layers, leaving a suction drain inside the cavity. Healing progressed uneventfully.  Histopathological examination revealed features consistent with lipoma. The tumour removed measured 21x17x14cm in size and weighed 2,95 Kg.

Specimen. Six months after surgery, the patient is symptom free and has no signs of recurrence

Lipoma  Lipoma is one of the commonest benign mesenchymal

tumour in the body composed of mature adipose cells.  It is found in almost all the organs of the body where

normally fat exists that is why it is also known as ubiquitous tumour or universal tumour.  Most of the lipomas present as small subcutaneous

swellings without any specific symptom.

Lipoma Giant lipomas, though rare, can present in thigh,

shoulder or trunk. Clinical features of these giant lipomas are mainly because of their size which includes pain because of stretching of adjacent nerves,(restriction in movements of the part involved or social embarrassment because of mere size of the swelling). Although definitive diagnosis of giant lipoma can be made only by histopathological examination, but once suspected, other investigations can provide additional information about the tumour.

Lipoma The characteristics of benign lipoms on

ultrasonography, CT and MRI have been well established and even Tc99 DTPA scan have been used to confirm the diagnosis.

Lipoma  Surgery is the treatment of choice of these giant swellings

due to their tendency to recur and their potential hazard of malignant transformation, other option for treatment of these giant swelling is liposuction.  The dissection of these lipomas is usually easy because of continuous pressure on the surrounding tissue, a well defined pseudocapsule is formed.  Dead space created because of dissection of the giant lipomas is usually drained with the help of a suction drain to avoid collection.  As already mentioned, these tumours have tendency to recur and can have malignant transformation, therefore, should be followed meticulously.

Lipoma

Hemangioma  Benign skin lesion consisting of dense,

usually elevated masses of dilated blood vessel.  Benign neoplasm characterized by blood vascular channels. A cavernous hemangioma consists of large vascular spaces.  A capillary hemangioma consists of many small blood vessels. A collection of dilated small vessels, 3 types: strawberry nevus, port-wine stains,

Cavernous hemangioma

Hemangioma  Congenital benign tumour made of blood vessels in the skin.  Capillary hemangioma , an abnormal mass of capillaries on the

head, neck, or face, is pink to dark bluish-red and even with the skin. Size and shape vary. It becomes less noticeable or disappears with age.  Immature hemangioma (hemangioma simplex, strawberry mark), a reddish nub of dilated small blood vessels, enlarges in the first six months and may become ulcerated but usually recedes after the first year.  Cavernous hemangioma, a rare, red-blue, raised mass of larger blood vessels, can occur in skin or in mucous membranes, the brain, or the viscera. Fully developed at birth, it is rarely malignant. Hemangiomas can often be removed by cosmetic surgery.

Strawberry nevus Intradermal, subdermal collection of dilated

blood vessels Congenital lesion- present at birth Looks like a strawberry Often regress spontaneously in months/years after birth Rubbed or knocked they may ulcerate and bleed

Strawberry nevus

Physical examination Position- any part of the body- head/neck> Color- bright or dark red Shape- protrude from the skin surface Size- usually- 1-2 cm. Surface-irregular Consistence- soft, compressible not pulsatile Relations- confined to the skin, freely mobile

over the deep tissues

Port-wine stain-extensive intradermal hemangioma, mostly venous

Cavernous hemangioma on the tongue

This angiogram (an X-ray taken after dye has been injected into the blood stream) shows a mass of blood vessels (hemangioma) in the liver.

Meningocele  Meningocele (MM):Protrusion of the membranes that

cover the spine and part of the spinal cord through a bone defect in the vertebral column.  MM is due to failure of closure during embryonic life of bottom end of the neural tube.  The term spina bifida refers specifically to the bony defect in the vertebral column through which the meningeal membrane and cord may protrude (spina bifida cystica) or may not protrude so that the defect remains hidden, covered by skin (spina bifida occulta).  The risk of MM (and all neural tube defects) can be

decreased by the mother eating ample folic acid during pregnancy.

A birth defect involving an abnormal opening in the spinal bones (vertebrae) is called spina bifida. The spinal vertebrae have not formed and joined normally, leaving an opening

A defect which also includes a small, moist sac (cyst) protruding through the spinal defect, containing a portion of the spinal cord membrane (meninges), spinal fluid, and a portion of spinal cord and nerves is called a meningocele, myelomeningocele, or meningomyelocele

Surgical treatment is needed to repair the defect and is usually done within 12 to 24 hours after birth to prevent infection, swelling, and further damage. While the baby is deep asleep and pain-free (using general anesthesia), an incision is made in the sac and some of the excess fluid is drained off. The spinal cord is covered with the membranes (meninges) and the skin is closed over the protruding meninges, spinal cord, and nerves.

The long-term result depends on the condition of the spinal cord and nerves. Outcomes range from normal development to paralysis (paraplegia). Infants may require about 2 weeks in the hospital after surgery.

Physical signs in head injury Examination of a case of recent head injury  The patient is unconscious  Examine the scalp for a wound or local bruising or

hematoma  Examine the nostrils and ears for evidence of blood diluted with CSF  Compare the size of the pupils and test their reaction to light  Make a general survey of the body for other injuries  Search for paralysis  Palpate and percuss the hypogastrium for evidence of an overfull bladder  Temperature, pulse rate, RR-charted every half-hour

Head injury Radiographs of the skull should be taken at

the first opportunity compatible with safety Brain injury is more likely in the presence of a

skull fracture BUT skull fracture of itself does not indicate brain injury

COMA Coma is a state of absolute unconsciousness

in which the patient does not respond to any stimulus Reflexes are absent, including the corneal and swallowing reflexes. Semi-coma- the patient responds only to painful stimuli and reflexes are present

Head injury The patient is conscious or semiconscious Patient with skull fracture – hospital admission Close observation: PR, BP, RR, pupil size and

reaction/ every ½ h. Signs of neurological deterioration: Falling pulse rate Reduced respiratory rate Falling GCS Dilatation of pupils Loss of light reaction or developing asymmetry

of pupils

Complications of traumatic brain injury Cranial bleeding Cerebral hypoxia Infection

Posttraumatic intracranial bleeding may be: - extradural - subdural - intracerebral CT of the brain documents the lesions Local brain compression- focal neurological effects

Types of skull fractures Liniar fractures - involve the skull vault,

- overlying scalp bruising or swelling Depressed fractures - caused by blunt

injuries, - the scalp is severely bruised Fractures of the base of the skull- anterior

fossa

Fracture of the anterior cranial fossa Periorbital hematoma Subconjunctival hemorrhage CSF running from the nose

Fracture of the middle cranial fossa CSF running from the ear or blood escaping

from the ear Bruising behind the ear over the mastoid area Risk of facial paralysis or deafness

Fracture of the posterior cranial fossa

Deep coma Bruising on the posterior wall of the pharynx

SKULL FRACTURES Linear skull fractures, the most common type

of skull fracture, occur in 69% of patients with severe head injury. Usually caused by widely distributed forces. In rare cases, a linear fracture can develop and lengthen as the brain swells, in what is called a growing fracture. Diastatic fractures are linear fractures that

cause the bones of the skull to separate at the skull sutures in young children whose skull bones have not yet fused. They are usually caused by

SKULL FRACTURES  Comminuted skull fractures, those in which a bone is

shattered into many pieces, can result in bits of bone being driven into the brain, lacerating it.  Depressed skull fractures, a very serious type of trauma

occurring in 11% of severe head injuries, are comminuted fractures in which broken bones are displaced inward.  This type of fracture carries a high risk of increasing pressure on the brain, crushing the delicate tissue. Complex depressed fractures are those in which the dura mater is torn. Depressed skull fractures may require surgery to lift the bones off the brain if they are causing pressure on it.

Basilar skull fracture  Basilar skull fractures, breaks in bones at the base of the

skull, require more force to cause than cranial vault fractures.  Thus they are rare, occurring as the only fracture in only 4%

of severe head injury patients.  Basilar fractures have characteristic signs: blood in the

sinuses; a clear fluid called cerebrospinal fluid (CSF) leaking from the nose or ears; raccoon eyes (bruising of the orbits of the eyes that result from blood collecting there as it leaks from the fracture site); and Battle's sign (caused when blood collects behind the ears and causes bruising).

Depressed skull fracture

Subdural hematoma

Intracerebral hematoma

Liniar skull fractures

Epidural hematoma

Liniar skull fracture

TRAUMA Leading cause of death and disability Trauma care involves multidisciplinary team Trauma care requires both speed and

accuracy Identification of life threats and emergent intervention may save life

TRAUMA 1. Prehospital care 2. Primary survey 3. Resuscitation 4. Secondary survey

PREHOSPITAL CARE Prehospital providers are trained in: Assessment of the injury scene Stabilization of the injured patient Monitoring and transport of critically ill patient

PREHOSPITAL CARE Efficient method for reporting by the

prehospital providers to the trauma team: M I V T M= mechanism of injury I= injury V= vital signs T= therapy

MECHANISM OF INJURY CAN PREDICT TYPES OF INJURIES FRONT-END COLLISION CAR: PATELLA

FRACTURE, POST. KNEE DISLOCATION, POPLITEAL ARTERY INJURY, FR. OF THE POST. RIM OF THE ACETABULUM HIGHT FALLS WITH LANDING ON FEET: CALCIS FR., LOWER EXTREMITIES FR., ACETABULAT FR., SPINE COMPRESSION FR. PEDESTRIANS STRUCK BY VEHICLES: CALF FR., HEAD INJURY, UPPER EXTREMITY INJURIES

INJURY INVENTORY A trapped patient- prolonged extrication: Rabdomyolisis Traumatic asphyxia Hypothermia

VITAL SIGNS LEVEL OF CONSCIOUSNESS- GLASGOW’S

COMA SCORE STABLE / UNSTABLE HEMODINAMICALLY RESPIRATION: CYANOSIS

GCS Less than or equal to 8 at 6 h.- 50% die Severe head injury 3 – 8 Moderate head injury 8-13 Mild head injury 14-15

False- hypothermia, intoxication, sedation Impossible to evaluate- dysphasic, intubated pts. and with facial or spinal cord injury

THERAPY AIMED TO STABILIZING THE PATIENT:

- SPINE AND EXTREMITY STABILIZATION - OXYGEN - I.V. FLUIDS - PREVENTION OF HEAT LOSS

INITIAL EVALUATION AND PRIMARY SURVEY HISTORY: A M P L E

PRIMARY SURVEY: A B C D E

AIRWAY ASSURING THE INTEGRITY OF THE AIRWAY IS

THE HIGHEST PRIORITY IN THE TRAUMA CARE

LOSS OF AIRWAY FUNCTION- IRREVERSIBLE

BRAIN DAMAGE WITHIN MINUTES

AIRWAY SUCTION JAW-THRUST MANOEVER GUEDEL PIPE TRACHEAL INTUBATION EMERGENT TRACHEOSTOMY

BREATHING Once airway established- give O2 Auscultation in the axillae Absence of BS- SIGNALS PT or HT

Chest motions Position of the trachea CXR IMMEDIATE DECOMPRESSION- CHEST

DRAINAGE TUBE

CIRCULATION Once airway and breathing secured-

assess circulation BP, PR, SKIN PERFUSION- CAPILLARY REFILL, MENTAL STATUS, URINE FLOW The most common cause of shok in trauma is hemorrhage:  two venous lines Obtain blood for cross-matching, FBC, ABG,

basic biochemistries

CIRCULATION CARDIAC SHOCK- due to cardiac tamponade

or tension pneumothorax Proeminent jugular venous distension Cool skin, pale, hypoperfused

NEUROGENIC SHOCK following a spinal cord

injury Paraplegia, quadriplegia Warm skin, absence of rectal tonus

DISABILITY Repeatedly GCS Pts. who : cannot follow a simple “ touch your nose” gross asymmetry of limb motion and pupils

Should be suspected of neurologic injuryEmergent brain CT SCAN

EXPOSURE Visual inspection of the entire patient Inspect the back- logrolling the pt. Inspect the perineum

RESUSCITATION Monitoring: ECG, BP, UO, PVC, CO, PO To assess the progress of resuscitation

SECONDARY SURVEY HEAD NECK THORAX ABDOMEN LIMBS

HEAD LACERATIONS STEP-OFFS GCS PUPILS CT

NECK HARD NECK COLLAR SPINE X RAY LOCAL TENDERNESS HEMATOMAS SUBCUTANEOUS EMPHYSEMA

THORAX LACERATIONS, WOUNDS SUBCUT. EMPHYSEMA CHEST MOTION BRUISING FLAIL CHEST BS

THORAX CARDIAC TAMPONADE NECK VEINS HEART SOUNDS ECHOCARDIOGRAPHY PULMONARY CONTUSION-

VENTILATION/PERFUSION MISMATCH

Life threatening condition

ABDOMEN BLUNT TRAUMA: Hemorrhagic abdomen- internal bleeding Peritonitic abdomen WOUNDS: Penetrating Perforating

Fracture of the pelvic bones

External fixation of the pelvis