Transcript 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
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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 cyst-specimen
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 mass.
 The weight of the specimen was 3.2kg.
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 the small strip of
skin denoted by the black
arrows).
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
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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,
 spider nevus
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
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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 semi-conscious
 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
- raised intracranial pressure
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
- middle fossa
- posterior 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 impact with a wide area such as a wall.
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:
 MIVT
 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,
biochemistries
basic
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